29-111 (10) I HAVE ATTEMPTED TO RESOLVE THIS PROBLEM BY DOING THE FOLLOWING:
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THEREFORE I AM ASKING THE COURT TO: Q
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PLEASE PRINT AFFIDAVIT PLEASE PRINT
THIS IS A REQUEST FOR AN EMERGENCY ORDER
UNDER THE PAINS AND PENALTIES OF PERJURY I SWEAR AND AFFIRM THAT:
MY NAME IS '�` . I Am The: t-oCcr l/ U41"
eG-"b rce � ' a on,,My Business Address is:
Telephone # ��
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I AM BRINGING THIS ACTION AGAINST: 61ort' a, a_j who
resides at G �o ; City Zip 0100- Phonegl`5 `3 y� 7 g y
THIS ACTION RELATES TO PROPERTY LOCATED AT:�', pS
(Explain the Defendant's relationship to the property): N] Owner [ ] Tenant [ ] Neighbor
[ ] Visitor [ ] Other :
On w v►� l- aO , The Following Occurred: (PRINT) y I a��-de aP
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(OVER)
PROOF OF SERVICE OF PROCESS
I hereby certify and return that on 20 1 served a copy of the
within summons and restraining orders, together with a copy of the complaint in this action, upon
the within named defendant, in the following manner [See Mass. R.Civ.P.4(d)(1-5)]:
Dated: , 20
Print Name Signature
N.B. TO PROCESS SERVER:
PLEASE PLACE THE DATE YOU MAKE SERVICE ON THE DEFENDANT IN THIS BOX ON
THE ORIGINAL AND ON COPY SERVED ON DEFENDANT.
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MArl ` - � � �
COMMONWEALTH OF MASSACHUSETTS
TRIAL COURT DEPARTMENT
WESTERN DIVISION HOUSING COURT
Case No. / (�/ Date:
Plaintiff(s Defendant(s)
may/ Street
Street�llr�7IQ�/}x� ��� U� // ,n i t!// oZ�
city/zip
City/Zip
(Property Owner/Manager)
APPLICATION FOR TEMPORARY RESTRAINING ORDER
Based upon the specific facts set out in the attached affidavit/verified complaint filed with the Clerk of this Court, I
request that the Court order the above Defendant(s)to desist and refrain from
AtI3
I also request the Court waive Rule 65(c) of MRCP that I provide security for the issuance of the above orders
because
Signed and sworn to under penalties of per ry this
befor fit Clerk-Magistrate. L' `
Sign f ure
************************************************************************** *****************
NOTICE OF HEARING ON TEMPORARY RESTRAINING ORDER
TO THE DEFENDANT: You are hereby notified that a hearing on the above application will be
held at the Western Division of The Housing Court, sitting in 116 Russell St. (Rte 9)
HADLEY, MA, on MONDAY 1j,Il/do at qAl_�"t which you may
appear and show cause why such application should not be an Cl.
WITNESS: Dina E. Fein, Esq. at Springfield