Commonwealth of Massachusetts The Trial Court Probate and Family Court Department Division Docket No. PETITION FOR GRANDPARENT(S) VISITATION Petitioner(s)-Please Print V. Respondent(s)-Please Print 1. Petitioner(s) who reside(s) at (Street Address) (County) (City/Town) is (are) the maternal grandmother (State) paternal grandmother maternal grandfather (Zip) paternal grandfather of said child(ren). 2. The Respondent, (name of respondent mother) who reside(s) at (Street Address) (City/Town) (County) (State) (Zip) and the respondent, (name of respondent father) who reside(s) at (Street Address) (City/Town) (County) (State) (Zip) are the parents of said child(ren). The parents do not live together. The Respondent, (e.g., the Department of Social Services, legal guardian, etc.) is responsible for the care-and custody-of the child(ren). 3. Petitioner(s) in this action seek(s) to obtain visitation rights with his/her/their grandchild(ren) namely: (name of child) (date of birth) (name of child) (date of birth) (name of child) (date of birth) (name of child) (date of birth) who is (are) unmarried minor(s) who reside(s) at (Street Address) (City/Town) CJ-D 105 (4/07) (County) Page 1 of 2 (State) (Zip) C.G.F American LegalNet, Inc. www.FormsWorkflow.com Commonwealth of Massachusetts The Trial Court Probate and Family Court Department Division Docket No. PETITION FOR GRANDPARENT(S) VISITATION 4. Please check and complete ONLY ONE of the following sections. a. ,the respondents were divorced by judgment of the Court. The judgment did not On provide for visitation rights for the above named grandparent(s). b. ,the repondent father was adjudicated by order/judgment to be the father of the On child(ren). The adjudicated father and the mother of the child(ren) do not reside together. The order/judgment did not provide for visitation rights for the above named grandparent(s). c. , the respondents signed an acknowledgment of parentage which was approved On by order/judgment of the court. The parents of the child(ren) do not reside together. The order/judgment did not provide for visitation rights for the above named grandparent(s). d. The respondents are married but living apart and are subject to a a temporary order or judgment of separate support. The order/judgment did not provide for visitation rights for the above named grandparent(s). e. On died leaving f. (name of deceased parent) as the surviving parent. (name of surviving parent) On died and on , (date of death) (date of death) (date of death) , (name of deceased parent(1)) , (name of deceased parent(2)) died. The child(ren) is/are currently (explain legal status of child(ren)'s care) Petitioner(s) is/are the maternal grandparent(s) of the above-named child(ren) whose parents were not wed at the time of his/her/their birth. g. 5. The child(ren) has/have not been adopted by a person other than a stepparent. 6. The petitioner(s) allege(s) that there exists a significant relationship between the grandparent(s) and the child(ren) and that it is in the best interest of the minor child(ren) that petitioner(s) be granted visitation with the child(ren). The petitioner(s) allege(s) that there does not exist a significant relationship between the grandparent(s) and the child(ren) but that nonetheless it is in the best interest of the minor child(ren) that petitioner(s) be granted visitation with the child(ren). Please attach an affidavit describing the nature of the involvement and relationship between the grandparent(s) and the granchild(ren); the circumstances surrounding either the curtailment or termination of contact; a description of current level of contact, if any; and a statement describing the significant harm to the child(ren)'s health, safety, or welfare likely to be suffered by the child(ren) if visitation is not ordered. WHEREFORE, petitioner(s) request(s) that this Court enter a judgment that provides him/her/them with visitation rights. SIGNED UNDER THE PENALTIES OF PERJURY. Date Signature (Petitioner 1) Tel. No. Signature (Petitioner 2) Tel. No. CJ-D 105 (4/07) Page 2 of 2 C.G.F American LegalNet, Inc. www.FormsWorkflow.com