JV-087 (Rev. 01/14/2019)
COUNTY[IES] DIVISION
Child's Name:
D.O.B.
The applicant is:
child's mother child's father child's legal guardian
custodian with custody of the child law enforcement/police officer
The applicant alleges that the above named child and the child's family require assistance as
defined in G.L. c. 119, § 21, in that said child who is between the ages of six and eighteen is a
sexually exploited child as defined in G.L. c. 119, § 21, and:
Date
is the victim of the crime of sexual servitude pursuant to section 50 of chapter 265 or is
the victim of the crime of sex trafficking as defined in 22 United States Code 7105;
Signature of Applicant
Print Name and Title
Address
Telephone Number
TRIAL COURT OF MASSACHUSETTS
JUVENILE COURT DEPARTMENT
DOCKET NO.
APPLICATION FOR CHILD REQUIRING ASSISTANCE
FOR SEXUALLY EXPLOITED CHILD
is a victim of the crime, whether or not prosecuted, of inducing a minor into prostitution
under section 4A of chapter 272; or
engages in common night walking or common streetwalking under section 53 of chapter
272.
engages, agrees to engage or offers to engage in sexual conduct with another person in
return for a fee, in violation of subsection (a) of section 53A of chapter 272, or in exchange
for food, shelter, clothing, education or care;
