Fill and Sign the Petition for Abuse Neglect Form

NHJB-2113-DF (12/01/2010) Page 1 of 1 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH h ttp ://www. cou rts.state .nh. us Court Name: Case Name: Case Number: (if known) IN THE MATTER OF , A CHILD PETITION FOR ABUSE / NEGLECT RSA 169-C NOTE: Pursuant to RSA 458-A, you must attach the Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit (Form NHJB-2660-DFPS) to this petition. 1. Petitioner Name: Telephone: Addre ss: 2. Child’s Name: Address: Date of Birth: Gender: Male Female Ethnicity: Hispanic Race: Asian Other Black Unavailable Non Hispanic Indian White Multiracial Native Hawaiian or Other Pacific Islander Refused 3. Legal Guardian of the child: Date of Birth: Addre ss: Telephone: 4. Father name: Date of Birth: Addre ss: Telephone: Mother name: Date of Birth: Addre ss: Telephone: 5. The petitioner represen ts that the child was abused neglected by: Nam e o f p ers o n: Addre ss: 6. Date(s) and time(s) of abus e/neglect: Location of abuse/neglect: 7. Details or facts of abuse/neglect (a ttach separate sheet if necessary): I swear or affirm that the foregoing information is true and correct to the best of my knowledge. Date Signature of Petitioner State of , County of This instrument was ackn owledged before me on by . My commission expires: Affix seal, if any Signature of Notarial Officer / Title ORDER AND NOTICE OF HEARING The foregoing petition having been presented, it is ordered that a hearing be held on at a.m./p.m. at the above-noted court and , the parents or legal guardian of the child, is /are hereby summoned to appear at the hearing. D ate C le rk /D eputy C le rk C: Mother Father Law Enforcement DCYF O th er: