THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) IN THE MATTER OF , A CHILD PETITION FOR ABUSE / NEGLECT RSA 169-C NOTE: Pursuant to RSA 458-A, you must attach the Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit (Form NHJB-2660-DFPS) to this petition. 1. Petitioner Name: Address: 2. Child's Name: Address: Date of Birth: Race: Asian Other Indian White 3. Legal Guardian of the child: Address: 4. Father name: Address: Mother name: Address: 5. The petitioner represents that the child was Name of person: Address: 6. Date(s) and time(s) of abuse/neglect: Location of abuse/neglect: 7. Details or facts of abuse/neglect (attach separate sheet if necessary): I swear or affirm that the foregoing information is true and correct to the best of my knowledge. Date Signature of Petitioner Telephone: Gender: Male Female Ethnicity: Black Unavailable Multiracial Native Hawaiian or Other Pacific Islander Date of Birth: Telephone: Date of Birth: Telephone: Date of Birth: Telephone: abused neglected by: Hispanic Non Hispanic Refused State of This instrument was acknowledged before me on My commission expires: Affix seal, if any , County of by Signature of Notarial Officer / Title . ORDER AND NOTICE OF HEARING The foregoing petition having been presented, it is ordered that a hearing be held on at a.m./p.m. at the above-noted court and , the parents or legal guardian of the child, is/are hereby summoned to appear at the hearing. Date Clerk/Deputy Clerk C: Mother Father Law Enforcement DCYF Other: American LegalNet, Inc. www.FormsWorkFlow.com NHJB-2113-DF (12/01/2010) Page 1 of 1