COUNTY[IES] DIVISION
TRIAL COURT OF MASSACHUSETTS
JUVENILE COURT DEPARTMENT
DOCKET NO.
PETITION FOR GRANDPARENT VISITATION
1. I/we,
request visitation with .
(name(s))
(child(ren)'s name(s))
2. I/we am/are the child(ren)'s:
_______________________________________
Signed under the pains and penalties of perjury.
_______________________________________
_______________________________________
ORDER
After a determination of what is in the best interest of the child(ren) by considering the goal of the service plan and
the relationship between the grandparent(s) and the child(ren)'s parent(s) or legal guardian(s), the within petition is
hereby:
ALLOWED
DENIED
(Petitioner's Signature/ Grandparent No. 1)
(Date)
(Date)
_______________________________________
(Justice)
, who reside at
(street and no.) (city or town) (state) (zip code)
3. The child(ren) is/are currently the subject of the following case(s) in this court:
Care and Protection
Children in Need of Services
4. The child(ren) is/are currently in the custody of:
Department of Children and Families
5. I have have not requested visitation from the custodian.
WHEREFORE, I request that the court grant me/us visitation with my/our grandchild(ren).
______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________
(Petitioner's Signature/ Grandparent No. 2)
_______________________________________
(Attorney's Signature (if applicable))
_______________________________________
(Date)
FOR COURT USE ONLY
(Telephone No.)
(BBO No.)
JV-53 (07/20/2010)
,
.
.
maternal grandparent(s). The child(ren)'s mother's name is:
paternal grandparent(s). The child(ren)'s father's name is:
Other: