State of Minnesota County Judicial District: Court File Number: Case Type: Juvenile District Court In the Matter of the Welfare of the Child(ren) of: Parent Parent Legal Custodian Legal Custodian Child In Need of Protection Or Services Petition To: District Court � Juvenile Division NOTICE TO PETITIONER: Minnesota Statutes � 260C.141, subd. 1(b), requires a petitioner to report any allegation of child abuse or neglect to the social services agency in the county where the child(ren) resides before filing a Petition with the Court. This Petition may be rejected if you have not first contacted the social services agency. 1. 2. My name is (name), and I am the Petitioner in this matter. I am not a county attorney or an agent of the Commissioner of Human Services. I have reported the information and circumstances alleged in this Petition to the social services agency in the county where the child(ren) resides, and the agency has declined to provide protection or services to the child (check one): FALSE (If "False," you must contact the social services agency before submitting this petition). TRUE, I have contacted the social services agency (please continue to Question 3). If you checked "True in Question 2," please complete the following and attach a copy of the social services denial, if one was prepared: a. Name of social services agency contacted: b. Date social services agency contacted: c. Date social services agency declined to provide protection or services: d. Reason(s) (if known) that social services agency declined to provide protection or services: 3. 4. I am related to the child(ren) or the child's parent(s) or custodian(s) (check one): NO, I am not related to the child(ren) or the child's parent(s) or custodian(s). YES, I am related as follows: I am not filing this Petition for the sole purpose of trying to change custody between the child(ren)'s parents (check one): TRUE FALSE State ENG Rev 7/15 www.mncourts.gov/forms Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com 5. CHP302 6. The name, date of birth, race, and address of the child(ren) are: Date Of Child's Name Birth Race Address 7. If known, the name, date of birth, race, and address of the child(ren)'s parent(s) or custodian(s) are: Parent(s) or Custodian(s) Date Of Name Birth Race Address 8. If different from the answer to Question 7, the name and address of the person(s) who have custody or control of the child(ren), or the child(ren)'s nearest known relative if no parent or guardian can be found, are: Name of Person(s) With Custody of Child(ren) Address CHP302 State ENG Rev 7/15 www.mncourts.gov/forms Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com 9. The name and address of the child's spouse (if any): Name of Child's Spouse (if any) Address 10. The child(ren) is/are enrolled or eligible for enrollment in an American Indian Tribe and, therefore, the Indian Child Welfare Act applies (check one): YES, and the name of the Tribe is: NO, the children are not enrolled in or eligible for enrollment in an American Indian Tribe. The facts upon which Petitioner relies for the assertion that the child(ren) is/are in need of protection or services are as follows (using an additional sheet of paper if necessary, describe in as much detail as possible why you believe the child(ren) is/are in need of protection or services, including names of persons involved and dates and times of events): 11. CHP302 State ENG Rev 7/15 www.mncourts.gov/forms Page 3 of 8 American LegalNet, Inc. www.FormsWorkFlow.com 12. A juvenile court or family court custody order exists, or a juvenile court or family court proceeding is pending, regarding the child(ren) (check one): UNKNOWN, I am unaware of any other files. NO, there are no other files. YES, there is another file with the following information: Case Name: County: File Number: The child(ren) is/are in need of protection or services within the meaning of the following provisions of Minnesota Statutes � 260C.007, subd. 6 (check one or more of the following): Subd. 6(1), because the child(ren) is/are abandoned or without parent, guardian, or custodian. Subd. 6(2), because the child(ren) (a) has/have been a victim(s) of physical or sexual abuse as defined in Minn. Stat. � 626.556, subd. 2; or (b) reside(s) with or has/have resided with a victim of domestic child abuse as defined in Minn. Stat. � 260C.007, subd. 13; (c) reside(s) with or would reside with a perpetrator of domestic child abuse or child abuse as defined in Minn. Stat. � 260C.007, subd. 13; or (d) is/are a victim(s) of emotional maltreatment as defined in Minn. Stat. � 260C.007, subd. 15. Subd. 6(3), because the child(ren) is/are without necessary food, clothing, shelter, education, or other required care for the child(ren)'s physical or mental health or morals because the child(ren)'s parent, guardian, or custodian is unable or unwilling to provide that care. Subd. 6(4), because the child(ren) is/are without the special care made necessary by a physical, mental, or emotional condition because the child(ren)'s parent, guardian, or custodian is unable or unwilling to provide that care. Subd. 6(5), because the child(ren) is/are medically neglected, which includes, but is not limited to, the withholding of medically indicated treatment from a disabled infant with a life-threatening condition. The term "withholding of medically indicated treatment" means the failure to respond to the infant's life-threatening conditions by providing treatment, including appropriate nutrition, hydration, and medication which, in the treating physician's or physicians' reasonable medical judgment, will be most likely to be effective in ameliorating or correcting all conditions, except that the term does not include the failure to provide treatment other than appropriate nutrition, hydration, or medication to an infant when, in the treating physician's or physicians' reasonable medical judgment: (i) the infant is chronically and irreversibly comatose; (ii) the provision of the treatment would merely prolong dying, not be effective in ameliorating or correcting all of the infant's life-threatening conditions, or otherwise be futile in terms of the survival of the infant; or (iii) the provision of the treatment would be virtually futile in terms of the survival of the infant and the treatment itself under the circumstances would be inhumane. 13. CHP302 State ENG Rev 7/15 www.mncourts.gov/forms Page 4 of 8 American LegalNet, Inc. www.F