Form 106 (Rev. 03/08) The Family Court of the State of Delaware In and For New Castle Kent Sussex County DEPENDENCY/NEGLECT PETITION FOR CUSTODY Petitioner 1 Petitioner 2 Name D.O.B. Name D.O.B. SSN SSN Street Address Street Address Apt. or P.O. Box Number File Number Apt. or P.O. Box Number City State Zip Code Petition Number City Attorney Name and Phone Number State Zip Code DFS Referral; Non-Relative Placement Attorney Name and Phone Number Respondent 1 Respondent 2 Name D.O.B. Name D.O.B. SSN SSN Street Address Street Address Apt. or P.O. Box Number Apt. or P.O. Box Number City State Zip Code City Attorney Name and Phone Number State Zip Code Attorney Name and Phone Number IN THE INTEREST OF: (Include last name.) Name DOB Name DOB Name DOB Name DOB Name DOB Name DOB Petitioner alleges the following facts: D.O.B. The Father is: D.O.B. The Mother is: SSN SSN Street Address Street Address Apt. or P.O. Box Number Apt. or P.O. Box Number City State Zip Code City 1 of 2 State Zip Code American LegalNet, Inc. www.FormsWorkflow.com Form 106 (Rev. 03/08) The above named children reside with: Name D.O.B. Street Address Apt. or P.O. Box Number City State Zip Code Check boxes below as appropriate: The child(ren) are: Dependent Neglected As defined by 10 Del.C. §901 [8] and [11] in that the children's physical, mental or emotional health and well being are threatened or impaired because of lack of necessary care and protection by the child's custodian who: Is unable to provide necessary care for the child. Has the ability and financial means to provide for the care but does not or will not provide necessary care, Or a child who has been abused or neglected as defined by 16 Del C. § 902. In support of the allegations in the preceding paragraph, the petitioner alleges the following facts: WHEREFORE, Petitioner prays that the aforementioned child(ren) be declared dependent/neglected and that custody be awarded to: Petitioner/Petitioner’s Attorney Date Sworn to subscribed before me this ______ day of ______________________, _________ Mediator/Notary Public 2 of 2 Date American LegalNet, Inc. www.FormsWorkflow.com