JV-110: California Juvenile Dependency Petition (Version Two)

Under attorney or party without attorney, enter the state bar no, name, firm name, street address, city, state, zip code, telephone no., fax no., e-mail address and attorney for (name).

Enter the superior court of California county, street address, mailing address, city and zip code, branch name and child's name.

Enter the CASE NUMBER.

Check § 300-Original, § 342-Subsequent or § 387-Supplemental.

Enter the RELATED CASE (if any).

Petitioner on information and belief alleges the following: the child named below comes within the jurisdiction of the juvenile court under the following subdivisions of section 300 of the Welfare and Institutions Code (check applicable subdivisions for each child; see attachment 1a for concise statements of facts).

Enter the Child's name, Age, Date of birth and Gender, and check all that apply under Section 300 subdivisions.

In c, enter the Name and Address, and check mother, father, guardian or unknown. If mother or father, check all that apply: legal, biological, presumed, alleged.

In d, enter the Name and Address, and check mother, father, guardian or unknown. For a mother or father, check legal, biological, presumed or alleged, all that apply.

In e, enter the Name and Address, and check mother, father, guardian or unknown; if mother or father, also check any of legal, biological, presumed or alleged that apply.

In f, Other, state name, address, and relationship to child. If no known parent or guardian resides within this state and this adult relative lives in this county or is closest to this court, check the box for "No known parent or guardian resides within this state".

In g, Prior to intervention, child resided with parent (name), guardian (name), Indian custodian (name) or other (state name, address, and relationship to child).

In h, Child is not detained or detained. If detained, enter the Date and time of detention and the Current place of detention (address): Relative, Shelter/foster care or Other.

Enter the CHILD'S NAME and CASE NUMBER.

Under Indian Child Welfare Act Inquiry, check one.

In a, you have asked whether the child is or may be a member of an Indian tribe or eligible for membership and the biological child of a member, and the Indian Child Inquiry Attachment (form ICWA-010(A)) is attached.

In b, on information and belief, you are aware that inquiry has been completed by (insert name) and the Indian Child Inquiry Attachment (form ICWA-010(A)) is attached.

In c, inquiry about whether the child is or may be a member of an Indian tribe or eligible for membership, and the biological child of a member has not yet been completed for the reasons set out. You are aware of the ongoing obligation to complete this inquiry and will complete the Indian Child Inquiry Attachment (form ICWA-010(A)), and submit it to the court as soon as possible.

In 3, Petitioner requests that the court find these allegations to be true.

Under penalty of perjury under the laws of the State of California, you declare that this form and all attachments are true and correct.

Enter the Date.

Type or print the name, and sign over SIGNATURE OF PETITIONER.

Enter the address and telephone number if a different person is signing than the one listed in the caption.

Enter the Number of pages attached.