Fill and Sign the Appendix 240 Court Specific Rules Concerning Form of

___________ : ______ JUDICIAL DISTRICT COURT VS. NO. ______ : PARISH OF ______ ___________ : STA TE OF LOUISIANA __________________________________________________________________ PETITION FOR TEMPORARY CARE, CUSTODY AND CONTROL The petition of ___________ , a resident of the full age of majority of the Parish of ______ , State of Louisiana, respectfully represents that: I. Petitioner, ___________ , is the father of the minor child, ___________ , whose date of birth is ______ ___ , 20 ___ . II. Petitioner avers that he has been granted the temporary care, custody and control of the minor child, pursuant to that certain order signed by the Honorable ___________ on the ___ day of ______ , 20 ___ . III. Petitioner avers that ___________ , the mother of the minor child, is presently a patient at a facility for the abuse of controlled dangerous subst ances. IV. Petitioner avers that he is currently receiving SSI benefits, has no transportation, and is unable to provide medical insurance for the minor child. V. Petitioner avers that ___________ and ___________ , his sister and brother -in - law, residents of ______ Parish, have agreed to provide medical insurance for the minor child until your petit ioner is capable of providing these necessities. VI. Petitioner avers that for ___________ and ___________ to be able to provide medical insurance, they must be awarded the temporary care, custody and control of the minor child, as required by the insurer. WHEREFORE, Petitioner prays that after due proceedings had, there be Judgment herein granting the temporary care, custody and control of the minor child, ___________ , to ____ _______ and ___________ . ___________ ___________ ______ , LA ______ (___ )______ La. Bar Roll No. ______ BY: ____________________________ ___________ ________________________________ ___________ ______________________________ ___________ ______________________________ ___________ ___________ : ______ JUDICIAL DISTRICT COURT VS. NO. ______ : PARISH OF ______ ___________ : STATE OF LOUISIANA ___________________________________________________ _______________ CONSENT JUDGMENT This matter came for hearing this date on motion of petitioner, ___________ . The Court, after reviewing the file and considering the stipulation of the parties, finds that there should be judgment herein in accordance with oral reasons this day assigned. IT IS ORDERED, ADJUDGED AND DECREED that there be judgment herein granting the temporary care, custody and control of the minor child, ___________ , to ___________ and ___________ . JUDGMENT READ, RENDERED AND SIGNED this ____ day of _________, 20 ___ . _______________________________ DISTRICT JUDGE APPROVED: ___________________________ ___________ ___________________________ ___________ ___________________________ ___________