COUNTY[IES] DIVISION TRIAL COURT OF MASSACHUSETTS JUVENILE COURT DEPARTMENT DOCKET NO. CARE AND PROTECTION PETITIONJV-F013 (Revised 03/21/2012)TO ANY JUSTICE OF THE JUVENILE COURT DEPARTMENT: SUBJECT CHILD OF THE PETITION: D.O.B. NAME ADDRESS CITY STATE ZIP CODE PETITIONER: AGENCY: NAME ADDRESS CITY STATE ZIP CODE RESPONDENTS: MOTHER'S NAMEFATHER'S NAME ADDRESS ADDRESS CITY STATE ZIP CODE CITY STATE ZIP CODE CARETAKER NAME ADDRESS CITY STATE ZIP CODETHE PETITIONER ALLEGES THAT THE ABOVE NAMED CHILD, is under the age of eighteen within the jurisdiction of this Court and is without necessary and proper physical or educational care and discipline; and/or is growing up under conditions or circumstances damaging to the child's sound character development; and/or lacks proper attention of parent(s), guardian with care and custody, or custodian; and/or whose parents, guardian or custodian are unwilling, incompetent or unavailable to provide any such care, discipline or attention. G.L. c.119, 247247 24-29. SIGNED UNDER PAINS AND PENALTIES OF PERJURY. (Petitioner's signature) DATE: INSTRUCTIONS: PLEASE PRINT OR TYPE American LegalNet, Inc. www.FormsWorkFlow.com