COUNTY[IES] DIVISION
TRIAL COURT OF MASSACHUSETTS
JUVENILE COURT DEPARTMENT
DOCKET NO.
PARENT/LEGAL GUARDIAN/CUSTODIAN
APPLICATION FOR CHILD REQUIRING ASSISTANCE
JV-086 (11/05/2012)
Child's Name:
D.O.B.
The applicant is the child's:
mother father legal guardian custodian with custody of the child
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:
repeatedly runs away from the home of a parent, legal guardian or custodian
OR
repeatedly fails to obey lawful and reasonable commands of a parent, legal
guardian, or custodian, thereby interfering with the parent's, legal guardian's
or custodian's ability to adequately care for and protect said child
Date
Signature of Applicant
Print Name and Title
Address
Telephone Number