JV-101(A) CHILD'S NAME: CASE NUMBER: 4. 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 3a for concise statements of facts): (c) (g) (d) (e) (f) (b)(1) (b)(2) (h) (i) (j) (a) b. Child's name: c. Age: d. Date of birth: e. Sex: Information is the same as that given for the child in item 1. (If not the same, provide different information below.) g. Name: f. Name: mother mother Address: Address: father father guardian guardian unknown 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 h. Name: Address: mother father guardian unknown biological presumed alleged i. Other (state name, address, and relationship to child): If mother or father (check all that apply): legal 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 detained Date and time of detention: Current place of detention (address): Relative Shelter/foster care Other 5. 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 3a for concise statements of facts): (c) (g) (d) (e) (f) (b)(1) (b)(2) (h) (i) (a) b. Child's name: c. Age: d. Date of birth: e. Sex: (j) Information is the same as that given for the child in item 1. (If not the same, provide different information below.) f. Name: g. Name: mother mother Address: Address: father father guardian guardian unknown 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 h. Name: Address: mother father guardian unknown biological presumed alleged i. Other (state name, address, and relationship to child): If mother or father (check all that apply): legal 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 detained Date and time of detention: Current place of detention (address): Relative Shelter/foster care Other 6. I have asked about Indian ancestry for each child and have completed and attached the required Indian Child Inquiry Attachment, form ICWA-010(A). Form Adopted for Mandatory Use Judicial Council of California JV-101(A) [Rev. July 1, 2016] ADDITIONAL CHILDREN ATTACHMENT Juvenile Dependency Petition Page 1 of 1 Welfare and Institutions Code, § 300; Cal. Rules of Court, rule 5.504 www.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com