Fill and Sign the Pursuant to Rsa 461 A13 Form

NHJB-2228-F (12/01/2010) Page 1 of 4 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) PETITION FOR GRANDPARENT VISITATION Pursuant to RSA 461-A:13 *If the parent of the minor child(ren) is unwed, any grandparent filing a petition under this section shall attach proof (for example, a copy of the birth certificate) of legitimation by the parent pursuant to RSA 460:29 or establishment of paternity. 1. Petitioner(s) Name(s) Date of Birth E-mail address Residence Address Mailing Address (if different) Telephone Number (Home) (Work) 2. Name of Mother Date of Birth E-mail address Residence Address Mailing Address (if different) Telephone Number (Home) (Work) 3. Name of Father Date of Birth E-Mail address Residence Address Mailing Address (if different) Telephone Number (Home) (Work) 4. If parents of children were married, list the date of marriage 5. Length of time child(ren) has been a resident of New Hampshire 6. List any minor children to be affected by this petition: Name Date of Birth Current Address Case Name: Case Number: PETITION FOR GRANDPARENT VISITATION NHJB-2228-F (12/01/2010) Page 2 of 4 Questions 7 – 11 are required under RSA 458-A, the Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA). It is important that you answer these questions with as much detail and accuracy as possible. Lack of adequate information could significantly delay orders being issued in your case. There are several situations that might result in New Hampshire exercising jurisdiction over child/ren. The continuous presence of the child/ren in New Hampshire for six (6) months is not the only basis for jurisdiction. In some emergency situations, the court may be able to exercise jurisdiction on a temporary basis. 7. List the places where the minor child/ren has/have lived in the last five (5) years and the names of the people they lived with at that time, if you know. Start wi th where the child lives now and work backward in time. Dates From/To Town/City, State Parent(s)/Care taker Current Address/Contact Address of Parent/Caretaker Which Child/ren If more space is needed, attach Extra Page (Form NHJB-2656-FP). I have attached Form NHJB-2656-FP because additional space was needed. 8. Are there any person(s), not a party to this proce eding, who have physical custody of the child/ren or who claim to have custody, physical custody or parenting time rights? Yes No If yes, list name(s) and address(es) of person(s): 9. Check one of the following: I have not participated in any court case(s) concerning the custody, visitation, parenting time or placement of the child/ren in this or any other state. OR I have participated in court case(s) concerning the custody, visitation, parenting time or placement of the child/ren in this or any other state. I have participated in the following: Name of Court State Case No. Date of Court Order Case Name: Case Number: PETITION FOR GRANDPARENT VISITATION NHJB-2228-F (12/01/2010) Page 3 of 4 10. Are there any actions for enforcement, or proceedings relating to domestic violence, domestic relations, protective orders, marriage dissolution, paternity, legitimation, custody, parental rights and responsibilities, termination of parental rights, adoption, juvenile, or other proceedings in any court in any state affecting any children named in this petition or parents of those children? Yes No If yes, complete the following: Name of Court State Case No. Type of Court Case 11. Optional: I am alleging, under oath, that my or my child/ren’s health, safety, or liberty would be jeopardized by the disclosure of identifying information set forth in this Petition. To support my allegation, I state as follows: 12. Please check one of the following regarding public assistance. No public assistance (TANF) is now being or has within the last 6 months been provided, nor is medical assistance (Medicaid) presently being provided, for any minor child listed above. The N. H. Department of Health and Human Services is providing or has provided within the last 6 months public assistance (TANF) and/or medical assistance (Medicaid) for a minor child or children listed above. If you check this box, you must mail copies of this petition and the personal data sheet to DHHS at: New Hampshire Department of Health and Human Services Division of Child Support Services - Legal Unit 129 Pleasant Street Concord, NH 03301 13. What orders do you want the court to make, and what reasons do you have, under RSA 461-A:13, for the court to make these orders? Case Name: Case Number: PETITION FOR GRANDPARENT VISITATION NHJB-2228-F (12/01/2010) Page 4 of 4 I acknowledge that I have a continuing duty to inform the court of any court action in this or any other state that could affect the child/ren in this case. 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 acknowledged bef ore me on by My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title Attorney for Petitioner(s) (if any) Printed Name, Address, E-mail, and Phone Number of Attorney (if any)