Fill and Sign the Petition to Terminate Parental Rights of Alleged Father San Form

THE ST A TE O F NEW H A M PSHIRE JUDI CI AL BR AN C H Cour t Na m e: Ca se Nam e: Term inati on of P arent al R ights of Ca se Num ber: (if k now n) PETITIO N F O R TERM IN ATIO N O F PA R ENTAL R IG HTS (RSA 170- C) Your peti tioner(s) repr esents th e following : 1. Peti tion er N ame T eleph one Petition er Na m e T eleph one Ma ilin g Address R esidence Ad dr ess 2. Attor ney Nam e T eleph one Ma ilin g Address 3. Peti tion er (s) relationshi p to c hild: Guar dian Par ent Foster Par ent Leg al C ustodi an Aut hor ized Ag ency Female 4 . Ch ild Na me Male Date o f Bir th Pl ace o f Bi rth R esidence Ad dr ess 5. Bi rth father nam e Date o f Bir th Mailing address Bi rth m oth er na me Date o f Bir th Mailing address 6. If ei ther par ent i s a mi nor, co mpl ete the fol lowing infor mati on as a ppl icabl e. Mater nal fath er Addr ess Mater nal mot her Addr ess Pater nal father Addr ess Pater nal moth er Addr ess NHJB-2188-FP (10/01/2006) Page 1 of 3 (formerly AOC-082E -003 and A OC-082E-00 8) Case Name: Termin ation of Par ental Rig hts o f Case Nu mb er: PETITION FOR TERM IN ATION OF P ARENT AL RIG HT S 7. The p erson hav ing custody /guar dianshi p/acti ng in loco pa re ntis or the or gani zati on or auth orized ag ency hav ing legal custody or pr ov iding car e for the chi ld i s: Na m e Addr ess 8. The co ur t h as j urisdi ction b ecaus e t he c hild is pr esen t in the Sta te or is in th e l egal cust ody or legal guar dianshi p of an au thor ized ag ency located in the st ate , and the c hild, p arent or guar dian r esides i n the coun ty. 9. Your peti tioner resp ect fully repr esents t hat ther e ar e s ufficient groun ds for the ter m inati on o f the par en tal rights o f ov er pur sua nt to R SA 17 0- C:5 du e t o: (Check th ose t hat ar e a ppl icable.) Aban do nm ent of the c hild Failur e to s upp or t, edu cate or car e for th e chil d Fai lure to c orrect co ndi tions o f neglect or abuse un der R SA 16 9- C Mental deficiency or mental illness of the par ent Sex ual , phy sical , em oti onal or m ental ab use of the chi ld Par ent is incar cer ated for a fel ony an d foun d, pur sua nt to R SA 16 9- C, to h ave ab used and neg lecte d th e chi ld. Par ent has be en c onv icted of one or m ore of the fol lowing off enses: (a) M urder , p ursuan t to R SA 630 :1- a or 63 0:1- b, o f an oth er chi ld of the par en t, a sibling or step- sibling of the chi ld, the chi ld’s other parent , or other pe rsons r elated by bl ood or mar riag e, i ncludi ng a mi nor chi ld who r esided w ith the defen dan t. (b) M ansl aug hter , pur suant to R SA 6 30: 2, of ano ther child of th e p arent, a si bling or step- sibling of the c hild, the chi ld’s other par ent, or oth er per so ns r elated by bl ood or mar riag e, i ncluding a mi nor child w ho r eside d w ith the de fend ant. (c) Atte mpt, pur su ant to R SA 629 :1, s olicitati on, pur sua nt to R SA 629:2 , or conspi racy , pur su ant to R SA 629 :3, to c ommit any of the offenses s peci fied in subp ar ag raphs ( a) or (b) abov e. (d) A felony assaul t un der R SA 631 :1, 63 1:2, 632- A: 2, or 63 2- A:3 w hich r esul ted i n injury to the c hild, a si bling or step- sibling of the chi ld, th e chi ld’s oth er par ent, or other per sons related by bl ood or mar riag e, i ncl udi ng a mi nor chi ld who r esi ded w ith the de fend ant. 10. Speci fy her e y our factu al al legations i n su ppor t o f your petition . NHJB-2188-FP (10/01/2006) Page 2 of 3 (formerly AOC-082E -003 and A OC-082E-00 8) Case Name: Termin ation of Par ental Rig hts o f Case Nu mb er: PETITION FOR TERM IN ATION OF P ARENT AL RIG HT S 11. If pe tition er s ar e foster par ents , th e fol lowing condi tions h ave bee n met: (a) The chi ld has l ived i n the foster hom e co nti nuousl y for 24 mo nths; and (b) The foster parents hav e r equeste d i n w riting the l icens ed c hild- placi ng ag ency to l egally free th e chi ld for adoption, but the ag ency has not i nitiated pr oc ee dings, and t her e i s reason abl e c ause to believe the g roun ds ex ist. 12. Your petition er asks that th e p arent al rig hts o f ov er be t erm inate d and t hat custo dy or guar dians hip o f be tr ansfer red to of Date Pet itioner Signa tur e Date Pet itioner Signa tur e State of This instrument w as acknow ledg ed be for e me on My C ommi ssi on Ex pires Affix Seal , if any , Coun ty of by Sig nat ure of Not arial O fficer / T itle To be complet ed b y Di vision f or Ch ildren, Y out h and Families ONLY . Cour t N ame Ca se Num ber Attor ney repr esenti ng par ents Addr ess T eleph one DCY F Attor ney Addr ess T eleph one DCYF Soci al W orker Addr ess T eleph one Ch ild 's G AL Addr ess T eleph one NHJB-2188-FP (10/01/2006) Page 3 of 3 (formerly AOC-082E -003 and A OC-082E-00 8)