Fill and Sign the Ca Jurisdiction Form

JV-365 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY ––––– ––––– ––––– TELEPHONE NO.: ––––– FAX 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: ––––– CHILD'S DATE OF BIRTH: ––––– HEARING DATE AND TIME: ––––– DEPT.: ––––– CASE NUMBER: TERMINATION OF DEPENDENCY JURISDICTION— ––––– CHILD ATTAINING AGE OF MAJORITY Directions for the social worker: Check the appropriate boxes in items 1 through 4, complete item 5, attach documents as required, and then sign and date item 6. Directions for the child (if available): Review the boxes checked by the social worker in items 1 through 4. Sign your initials after each item that correctly indicates the information and services that you have received. Then sign and date item 7. 1. a. The child has indicated that he or she intends to be present at the termination hearing. b. The child does not wish to attend the termination hearing. The petitioner has attached verification that the child has been informed of the potential consequences of failure to attend the termination hearing. c. The child is unavailable and/or has refused to sign this form. Evidence of reasonable efforts to locate the child and to obtain the child’s signature is attached. 2. Attached is a report verifying that the child has received written information concerning his or her dependency case— including information about the child’s family history, the child's placement history, the whereabouts of any siblings under the jurisdiction of the juvenile court, the procedures for accessing the documents that the child is entitled to inspect under Welfare and Institutions Code section 827, and the date on which the jurisdiction of the court will be terminated. 3. The child has been provided with the following documents: a. Certified birth certificate b. Social security card c. Identification card and/or driver’s license d. Proof of citizenship or residency status e. Death certificate of parent or parents, if applicable Page 1 of 2 Form Adopted for Mandatory Use Welfare and Institutions Code, § 391 Judicial Council of California California Rules of Court, rule 1466 JV-365 [Rev. January 1, 2006] TERMINATION OF DEPENDENCY JURISDICTION— CHILD ATTAINING AGE OF MAJORITY (Juvenile) electronic form ã 2005 WWW.LawCA.co m Law Publishers JV-365 CHILD'S NAME: CASE NUMBER: ––––– ––––– 4. The following assistance has been provided to the child: a. Application for Medi-Cal or other health insurance has been completed. b. Application for college, vocational training program, or other educational or employment program has been completed. c. Information on obtaining, or application to obtain, financial assistance for educational and employment programs has been provided. d. Referral to transitional housing, if available, or assistance in securing other housing has been provided. e. Assistance in obtaining employment or other financial support has been provided. f. Assistance in maintaining relationships with individuals who are important to the child, consistent with the child's best interest, has been provided. (Required only if the child has been in out-of-home placement in a group home for six months or longer from the date the child entered foster care.) g. Other services have been ordered by the court (specify): ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– 5. Number of pages attached: ––––– 6. I declare under penalty of perjury under the laws of the State of California that the foregoing and all attachments are true and correct. Date: ––––– ––––– (TYPE OR PRINT NAME) (SIGNATURE OF SOCIAL WORKER) 7. I certify that I have received the information and services that I initialed above. Date: ––––– ––––– (TYPE OR PRINT NAME) (CHILD'S SIGNATURE) JV-365 [Rev. January 1, 2006] TERMINATION OF DEPENDENCY JURISDICTION— Page 2 of 2 CHILD ATTAINING AGE OF MAJORITY (Juvenile)