For counties filing a separate dependency petition for each child or for counties using Additional Children Attachment (form JV-101(A)) ATTORNEY OR PARTY WITHOUT ATTORNEY: NAME: FIRM NAME: STREET ADDRESS: CITY: TELEPHONE NO.: E-MAIL ADDRESS: ATTORNEY FOR (name): STATE: FAX NO.: ZIP CODE: STATE BAR NO.: FOR COURT USE ONLY JV-100 SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: CHILD'S NAME: JUVENILE DEPENDENCY PETITION (VERSION ONE) (Welf. & Inst. Code, § 300 et seq.) § 300--Original § 342--Subsequent § 387--Supplemental CASE NUMBER: RELATED CASE (if any): 1. Petitioner on information and belief alleges the following: a. 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 boxes; see attachment 1a for concise statements of facts): (a) (b)(1) (b)(2) (c) (d) (e) (f) (g) (h) (i) (j) e. Sex: c. Age: d. Date of birth: b. Child's name: f. Name: Address: mother father guardian unknown If mother or father (check all that apply): legal biological presumed alleged If mother or father (check all that apply): legal biological presumed alleged g. Name: Address: mother father guardian unknown h. Name: Address: mother father guardian unknown i. Other (state name, address, and relationship to child): If mother or father (check all that apply): legal biological presumed alleged No known parent or guardian resides within this state. This adult relative lives in this county or is closest to this court. j. Prior to intervention, child resided with parent (name): parent (name): guardian (name): Indian custodian (name): other (state name, address, and relationship to child): k. Child is not detained Date and time of detention: detained Current place of detention (address): Relative 2. Shelter/foster care Other I have asked about Indian ancestry for this child and have completed and attached the required Indian Child Inquiry Attachment, form ICWA-010(A). (If this is a subsequent filing and there is no new information, form ICWA-010(A) is not required.) (See important notice on page 2.) Form Adopted for Alternative Mandatory Use Instead of Form JV-110 Judicial Council of California JV-100 [Rev. July 1, 2016] Page 1 of 2 Welfare and Institutions Code, § 300 et seq.; Cal. Rules of Court, rule 5.504 www.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com JUVENILE DEPENDENCY PETITION (VERSION ONE) JV-100 CHILD'S NAME: CASE NUMBER: 3. Petitioner requests that the court find these allegations to be true. I declare under penalty of perjury under the laws of the State of California that the foregoing and all attachments are true and correct. Date: (TYPE OR PRINT NAME) (SIGNATURE OF PETITIONER) Address and telephone number (if different person signing than listed in caption above): Number of pages attached: Other children are listed on Additional Children Attachment (form JV-101(A)) -- NOTICE -- TO PARENT Your parental rights may be permanently terminated. To protect your rights, you must appear in court and answer this petition. TO PARENTS OR OTHERS LEGALLY RESPONSIBLE FOR THE SUPPORT OF THE CHILD You and the estate of your child may be jointly and severally liable for the cost of the care, support, and maintenance of your child in any placement or detention facility, the cost of legal services for you or your child by a public defender or other attorney, and the cost of supervision of your child by order of the juvenile court. JV-100 [Rev. July 1, 2016] JUVENILE DEPENDENCY PETITION (VERSION ONE) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com