COMPLAINT YOUTH IN CRISIS STATE OF CONNECTICUT SUPERIOR COURT JD-JM-142 Rev. 9-02 C.G.S. § 46b-120, 46b-121, 46b-150f Public Act 02-109, Sec. 1 TO: The Superior Court, Juvenile Matters JUVENILE MATTERS www.jud.ct.gov PRINT OR TYPE. If necessary, attach additional information. ADDRESS OF COURT DOCKET NO. NAME OF YOUTH ADDRESS OF YOUTH NAME OF MOTHER ADDRESS OF MOTHER NAME OF FATHER ADDRESS OF FATHER NAME OF GUARDIAN, IF ANY ADDRESS OF GUARDIAN INDIAN TRIBE/RESERVATION, IF ANY SEX DATE OF BIRTH SCHOOL/GRADE COMPLAINT The undersigned believes that the above youth is a youth in crisis because said youth is sixteen or seventeen years of age, and, within the last two years: ("X" appropriate box(es)) has without just cause run away from the parental home or other properly authorized and lawful place of abode; is beyond the control of parents, guardian or other custodian; OR has four unexcused absences from school in any one month or ten unexcused absences in any school year. For each box checked above, describe in detail the acts or omissions of said youth upon which the complaint is made. (Be specific and include dates.) COMPLAINANT'S SIGNATURE AGENCY AND TITLE (If applicable) DATE SIGNED NOTICE: The youth may not be placed in detention based on this complaint. American LegalNet, Inc. www.FormsWorkflow.com