TO ANY JUSTICE OF THE JUVENILE COURT DEPARTMENT:
SUBJECT CHILD OF THE PETITION:____________________________________________ D.O.B. _____________
NAME
_______________________________________________________________________________________________
ADDRESS CITY STATE ZIP CODE
PETITIONER:
__________________________________________________ AGENCY: ___________________________________
NAME
_______________________________________________________________________________________________
ADDRESS CITY STATE ZIP CODE
RESPONDENTS:
______________________________________________ ____________________________________________
MOTHER'S NAME FATHER'S NAME
______________________________________________ _____________________________________________
ADDRESS ADDRESS
______________________________________________ _____________________________________________
CITY STATE ZIP CODE CITY STATE ZIP CODE
_______________________________________________________________________________________________
CARETAKER
_______________________________________________________________________________________________
NAME
_______________________________________________________________________________________________
ADDRESS CITY STATE ZIP CODE
THE PETITIONER ALLEGES THAT THE ABOVE NAMED CHILD, is under the age of eighteen within the jurisdiction
of this Court and is without necessary and proper physical or educational care and discipline; and/or is growing up under
conditions or circumstances damaging to the child's sound character development; and/or lacks proper attention of
parent(s), guardian with care and custody, or custodian; and/or whose parents, guardian or custodian are unwilling,
incompetent or unavailable to provide any such care, discipline or attention. G.L. c.119, §§ 24-29.
SIGNED UNDER PAINS AND PENALTIES OF PERJURY.
