41-009 (13) I HAVE ATTEMPTED TO RESOLVE THIS PROBLEM BY DOING THE FOLLOWING:
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THEREFORE I AM ASKING THq-CPURT TO:
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S 4ED DATE
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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: ,g
�n5p.���o� o.n or►.' �. -,� D °,My Business Address is:
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1 AM BRINGING THIS ACTION AGAINST: D"yj who
resides at / e5a onity� Zip d 0 Phone
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THIS ACTION RELATES TO PROPERTY LOCATED AT: 010LO
(Explain the Defendant's relationship to the property): M Owner [ ] Tenant [ ] Neighbor
[ ]Visitor [ ] Other :
On M, 028 , The Following Occurred: (PRINT) - — �►� e,Sfi
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PROOF OF SERVICE OF PROCESS
I hereby certify and return that on 200 1 served a copy of the within
summons and restraining orders, togetherwith 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)j:
Dated: , 200_.
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.
( , 200 )
sir
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COMMONWEALTH OF MASSACHUSETTS
= THE TRIAL COURT
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HOUSING COURT DEPARTMENT
WESTERN DIVISION
37 ELM STREET - P.O. BOX 559
SPRINGFIELD, MA 01 102-0559
TELEPHONE (413) 748-7838
FAX (413) 732-4607
DINA E. FEIN PETER Q. MONTORI
FIRST JUSTICE CLERK MAGISTRATE
ROBERT G. FIELDS KEVIN R. BYRNE, SR.
ASSOCIATE JUSTICE CHIEF HOUSING SPECIALIST
Case No. (� ��1 ( Date:
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Plaintiff s) �y Def ndant(s),,
Street Street
City/Zip City/Zip
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
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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 perjury this
before Clerk-Magistrate. Signature
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
West rn Divjjsion of Th Housing Court,sitting in 116 Russell St. (Rte 9) HADLEY, MA,on MONDAY
at 9:00 a.m. at which you may appear and show cause why such
app Ic tion sh uld not/be granted.
WITNESS: Dina E. Fein, Esq. at Northampton