JV-210
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number and mailing address):
FOR COURT USE ONLY
FAX NO. (Optional):
TELEPHONE NO. (Optional):
E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
CHILD'S NAME:
CASE NUMBER:
APPLICATION TO COMMENCE PROCEEDINGS BY AFFIDAVIT
AND DECISION BY SOCIAL WORKER
(Welf. & Inst. Code, § 329)
To the social worker or social services agency of (specify county):
2. My name and address:
3. My relationship to the child described below (specify):
4. I am providing the following information about the child.
a. Child's name:
b. Age:
c. Date of birth:
d. Sex:
e. Mother's name:
f. Mother's address:
g. Father's name:
h. Father's address:
i. Other (state name, address, and relationship to child):
resides within this county.
a.
b.
6. Facts in support (state supporting facts concisely and include all known and relevant dates, times, names, and addresses. Attach
separate pages as necessary):
See attachment 6. Number of pages attached:
Date:
(SIGNATURE OF APPLICANT)(TYPE OR PRINT NAME)
APPLICATION TO COMMENCE PROCEEDINGS BY AFFIDAVIT
AND DECISION BY SOCIAL WORKER
(Welf. & Inst. Code, § 329)
Form Approved for Optional Use
Judicial Council of California
JV-210 [Rev. July 1, 2010]
Welfare and Institutions Code, § 329
5. The child described in item 4 above
was in this county at the time of the facts alleged below.
Page 1 of 2
7. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
1. I allege that the child described below is being abused or neglected or at risk of abuse or neglect as defined in Welfare and
Institutions Code section 300. I request that the social worker or agency immediately begin proceedings in the juvenile court on
behalf of the child described below.
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