STATE OF MAINE DISTRICT COURT Location Docket No. Petitioner v. Respondent VERIFIED APPLICATION FOR ISSUANCE OF WARRANT 19-A M.R.S.A. § 1771 I am the Petitioner in the above captioned matter, having filed a petition seeking expedited enforcement of a child custody determination under the UCCJEA. I file this verified application for the issuance of a warrant to take physical custody of the child(ren) named in the petition because the child(ren) is/are likely to: imminently suffer serious physical harm based on the following grounds and on the following facts: be removed from this state based on the following grounds and on the following facts: The present physical address/location of the minor child(ren) and Respondent is: The custody determination order did did, the basis for jurisdiction was as follows: did not state the basis for that court’s jurisdiction. If it The custody determination order has has not been vacated, stayed or modified. (If vaca ted, stayed or modified state the name and address of the court, date vacated, stayed or modified, and nature of the proceeding and attach a copy of the order. The custody determination order has has not been registered and confirmed in any state court. (If it has, list the name, address, docket number, and phone number of the court where registered): The following court proceedings/actions have been commenced and could affect the custody determination order (Protection from Abuse, Child protection, criminal or any other parental rights and responsibilities proceeding). (List court, address, type of proceeding / action, date of orders, and type of orders): Date: Petitioner Personally appeared the above named above statements are true. , and swore that the Date: Notary Public / Clerk Application for Issuance of Warrant ORDER Granted Denied Date: FM-181, 08/04 PAN Judge, District Court American LegalNet, Inc. www.USCourtForms.com