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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CHILD'S NAME:
CASE NUMBER:
JV-210 [Rev. July 1, 2010)
JV-210
DECISION OF SOCIAL WORKER OR SOCIAL SERVICES AGENCY
9. After consideration of the application above, the SOCIAL WORKER HAS DECIDED
to commence proceedings in juvenile court on these allegations. a.
b.
See attachment 9. Number of pages attached:
Date:
(SIGNATURE OF SOCIAL WORKER)
(TYPE OR PRINT NAME)
not to commence proceedings in juvenile court on these allegations because (specify):
Page 2 of 2
APPLICATION TO COMMENCE PROCEEDINGS BY AFFIDAVIT
AND DECISION BY SOCIAL WORKER
(Welf. & Inst. Code, § 329)
8. Social worker information:
a. Name:
b. Agency:
c. Address:
d. Telephone number:
10. I declare I am a social worker of the county in which this application was submitted and am duly authorized to make this decision.
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