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File No. Name And Address Of Juvenile Name Of Petitioner Juvenile’s Date Of Birth Age Race Sex JUVENILE PETITION (UNDISCIPLINED) G.S. 7B-1501(27), -1703, -1706, -1801, -1802 I have suf�cient knowledge or information to believe that a case has arisen that invokes the juvenile jurisdiction of the court, and therefore allege that: 1. The juvenile named above is under the age of eighteen (18) and committed an undisciplined act in this district. 2. The names, addresses, and telephone numbers of the juvenile’s parents, guardian, or custodian are as follows: 3. The juvenile is an undisciplined juvenile, in that on or about: (date or time period) ______________________________________ , the juvenile a. was regularly disobedient to the juvenile’s parent, guardian, or custodian and beyond their disciplinary control. b. was regularly found in places where it is unlawful for a juvenile to be. c. ran away from home for a period of more than 24 hours. d. while less than sixteen (16) years of age, was unlawfully absent from school. Speci�cally, the juvenile: (State facts supporting the alleged offense(s).) STATE OF NORTH CAROLINA County In The General Court Of Justice District Court Division IN THE MATTER OF Name Relationship/Title Address Telephone No. (See reverse side for ADDITIONAL FACTS AND CIRCUMSTANCES ) NC-JOIN No. AOC-J-230, Rev. 12/17 © 2017 Administrative Of�ce of the Courts DECISION OF COURT COUNSELOR REGARDING THE FILING OF THE PETITION I request the Court to hear the case to determine whether the allegations are true and whether the juvenile is within the jurisdiction of the Court as an undisciplined juvenile. ADDITIONAL FACTS AND CIRCUMSTANCES VERIFICATION Being �rst duly sworn, I say that I have read the allegations in the petition and that the same are true to my own knowledge, except as to those matters alleged upon information and belief, and as to those, I believe them to be true. WITNESS(ES) Date My Commission Expires County Where NotarizedSignature Of Petitioner Date City, State, Zip Address Agency (if applicable) Telephone No. Signature Of Person Authorized To Administer Oaths Notary SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME SEAL Name Address Telephone No. Deputy CSC Assistant CSC Clerk Of Superior Court Magistrate Date Complaint Received By Juvenile Justice Section Of The Division Of Adult Correction And Juvenile Justice Pursuant to G.S. 7B-1703, at the discretion of the undersigned chief court counselor, the time to �le a petition in the above captioned case is extended 15 days. Date Name Of Chief Court Counselor Signature Of Chief Court Counselor 15-DAY EXTENSION OF TIME TO FILE PETITION Post-Diversion Approval For Filing Of Petition Signature Of Court Counselor Signature Of Court Counselor Date Date Date Time Name Of Court Counselor Giving Telephonic Approval Name And Title Of Person Receiving Telephonic ApprovalSignature Of Person Receiving Telephonic Approval 1. Approved for Filing 2. Not Approved for Filing a. Closed b. Diverted and Retained AM PM Approved for Filing Title Or Relationship To Juvenile (if applicable) AOC-J-230, Side Two, Rev. 12/17 © 2017 Administrative Of�ce of the Courts