JU03 0100 Dependency Petition by 4mD4ar

VIEWS: 12 PAGES: 3

									 SUPERIOR COURT OF WASHINGTON
 COUNTY OF _______________________
              JUVENILE COURT

 Dependency of:                                                  No:

                                                                 Dependency Petition
 D.O.B.:
                                                                 (DPP)

                                                     I. Basis
I represent to the court the following:

1.1    Child alleged to be dependent:                                                     [ ] male [ ] female
 Name
 Date of Birth

 Home Address

1.2     Parent(s) or Legal Guardian(s):

                              [ ] Mother                               [ ] Father [ ] presumed [ ] alleged
                              1                                        2
 Name
 Date of Birth
 Marital status               [ ] single [ ] married [ ] other         [ ] single [ ] married [ ] other
 Driver’s License or
 Identicard (# and State)

 Home Address

                              [ ] Father [ ] presumed [ ] alleged      [ ] Custodian/Legal Guardian
                              3                                        4
 Name
 Date of Birth
 Marital status               [ ] single [ ] married [ ] other
 Driver’s License or
 Identicard (# and State)

 Home Address
                                                                  FOR OFFICIAL USE ONLY
                                                                  Juv. Ref. No:______________________
Dependency Petition (DPP) – Page 1 of 3
WPF JU 03.0100 (07/2011) – JuCR 3.3; RCW 13.34.030, .040
1.3    Child’s Indian Status:

       [ ]    The petitioner has made the following efforts and cannot determine whether the child is
              an Indian child as defined in Laws of 2011, ch. 309, §4:


                                                                                                         .
       [ ]    Based upon the following, the child is not an Indian child as defined in Laws of 2011, ch.
              309, §4, and the federal and Washington State Indian Child Welfare Acts do not apply to
              these proceedings:


                                                                                                         .
       [ ]    Based upon the following, the child is an Indian child as defined in Laws of 2011, ch. 309,
              §4 and the federal and Washington State Indian Child Welfare Acts do apply to these
              proceedings:


                                                                                                         .
       [ ]    The petitioner has made the following preliminary efforts to provide notice of these
              proceedings to all tribes to which the petitioner knows or has reason to know the child
              may be a member or eligible for membership:


                                                                                                         .

1.4    Dependency: The child should be declared dependent according to RCW13.34.030 as follows:

       [ ]    (a) the child has been abandoned as defined in RCW 13.34.030;
       [ ]    (b) the child is abused or neglected as defined in chapter 26.44 RCW; or
       [ ]    (c) the child has no parent, guardian or custodian capable of adequately caring for the child,
              such that the child is in circumstances which constitute a danger of substantial damage to
              the child’s psychological or physical development.

1.5    Allegations: The allegation of Dependency is based on the following facts:
       _____________________________________________________________________________
       _____________________________________________________________________________
       _____________________________________________________________________________
       _____________________________________________________________________________
       _____________________________________________________________________________
       _____________________________________________________________________________
       _____________________________________________________________________________
       _____________________________________________________________________________
       _____________________________________________________________________________
       _____________________________________________________________________________
       _____________________________________________________________________________
       _____________________________________________________________________________

Dependency Petition (DPP) – Page 2 of 3
WPF JU 03.0100 (07/2011) – JuCR 3.3; RCW 13.34.030, .040
        _____________________________________________________________________________
        _____________________________________________________________________________
        _____________________________________________________________________________
        _____________________________________________________________________________.


                                             II. Relief Requested
I request that the court inquire into this matter and enter such order as the court finds just and in the best
interest of the child.

Dated: _____________________________                        ______________________________________
                                                            Petitioner


                                                            ______________________________________
                                                            Type or Print Name/Title   WSBA No.

                                              III. Certification
I declare under penalty of perjury under the laws of the State of Washington that the foregoing
representations are true and correct.



Signed at _____________________________(City), Washington on _______________________(Date).


_________________________________________                   ______________________________________
Signature                                                   Print Name




Dependency Petition (DPP) – Page 3 of 3
WPF JU 03.0100 (07/2011) – JuCR 3.3; RCW 13.34.030, .040

								
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