NHJB-2188-F (03/26/2019) Page 1 of 5 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) Termination of Parental Rights of: over Parent Child PETITION FOR TERMINATION OF PARENTAL RIGHTS RSA 170-C Your petitioner(s) represents the following: 1. Petitioner Name Telephone Petitioner Name Telephone Mailing Address Residence Address 2. Attorney Name Telephone Mailing Address 3. Petitioner(s) relationship to child: Guardian Parent Foster Parent Legal Custodian Authorized Agency 4. Child Name Male Female Date of Birth Place of Birth Residence Address 5. Birth father name Date of Birth Mailing address Birth mother name Date of Birth Mailing address 6. If either parent is a minor, complete the following information as applicable. Maternal father Address Maternal mother Address Paternal father Address Paternal mother Address American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Termination of Parental Rights of Case Number: PETITION FOR TERMINATION OF PARENTAL RIGHTS NHJB-2188-F (03/26/2019) Page 2 of 5 7. The person having custody/guardianship/acting in loco parentis or the organization or authorized agency having legal custody or providing care for the child is: Name Address 8. The court has jurisdiction because the child is present in the State or is in the legal custody or legal guardianship of an authorized agency located in the state, and the child, parent or guardian resides in the county. 9. Your petitioner respectfully represents that there are sufficient grounds for the termination of the parental rights of over pursuant to RSA 170-C:5 due to: (Check those that are applicable.) Abandonment of the child Failure to support, educate or care for the child Failure to correct conditions of neglect or abuse under RSA 169-C Mental deficiency or mental illness of the parent Sexual, physical, emotional or mental abuse of the child Parent is incarcerated for a felony and found, pursuant to RSA 169-C, to have abused and neglected the child. Parent has been convicted of one or more of the following offenses: (a) Murder, pursuant to RSA 630:1-a or 630:1-b, of another child of the parent, a sibling or step-sibling of the child, the child222s other parent, or other persons related by blood or marriage, including a minor child who resided with the defendant. (b) Manslaughter, pursuant to RSA 630:2, of another child of the parent, a sibling or step-sibling of the child, the child222s other parent, or other persons related by blood or marriage, including a minor child who resided with the defendant. (c) Attempt, pursuant to RSA 629:1, solicitation, pursuant to RSA 629:2, or conspiracy, pursuant to RSA 629:3, to commit any of the offenses specified in subparagraphs (a) or (b) above. (d) A felony assault under RSA 631:1, 631:2, 632-A:2, or 632-A:3 which resulted in injury to the child, a sibling or step-sibling of the child, the child222s other parent, or other persons related by blood or marriage, including a minor child who resided with the defendant. (e) Has been convicted of or who has pled guilty or nolo contendere to a violation of sexual assault as defined in RSA 632-A:2 through RSA 632-A:4, or a similar statute in another state against the birth mother for his conduct in fathering the child; 10. Specify here your factual allegations in support of your petition. American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Termination of Parental Rights of Case Number: PETITION FOR TERMINATION OF PARENTAL RIGHTS NHJB-2188-F (03/26/2019) Page 3 of 5 11. If petitioners are foster parents, the following conditions have been met: (a) The child has lived in the foster home continuously for 24 months; and (b) The foster parents have requested in writing the licensed child-placing agency to legally free the child for adoption, but the agency has not initiated proceedings, and there is reasonable cause to believe the grounds exist. Questions 12-17 are required under RSA 458-A, the Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA). It is important that you answer these questions with as much detail and accuracy as possible. Lack of adequate information could significantly delay orders being issued in your case. There are several situations that might result in New Hampshire exercising jurisdiction over child/ren. The continuous presence of the child/ren in New Hampshire for six (6) months is not the only basis for jurisdiction. In some emergency situations, the court may be able to exercise jurisdiction on a temporary basis. 12. List minor children born to or adopted by the parties: Name Date of Birth Current Address 13. List the places where the minor child/ren of the parties has/have lived in the last five (5) years and the names of the people they lived with at that time, if you know. Start with where the child lives now and work backward in time. Dates From/To Town/City, State Parent(s)/Caretaker Current Address/Contact Address of Parent/Caretaker Which Child/ren If more space is needed, attach Extra Page (Form NHJB-2656-FP). I have attached Form NHJB-2656-FP because additional space was needed. 14. Are there any person(s), not a party to this proceeding, who have physical custody of the child/ren or who claim to have custody, physical custody or parenting time rights? Yes No If yes, list name(s) and address(es) of person(s): American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Termination of Parental Rights of Case Number: PETITION FOR TERMINATION OF PARENTAL RIGHTS NHJB-2188-F (03/26/2019) Page 4 of 5 15. Check one of the following: I have not participated in any court case(s) concerning the custody, visitation, parenting time or placement of the child/ren in this or any other state. OR I have participated in court case(s) concerning the custody, visitation, parenting time or placement of the child/ren in this or any other state. I have participated in the following: Name of Court State Case No. Date of Court Order 16. Are there any actions for enforcement, or proceedings relating to domestic violence, domestic relations, protective orders, marriage dissolution, paternity, legitimation, custody, parental rights and responsibilities, termination of parental rights, adoption, juvenile, or other proceedings in any court in any state affecting any children named in this petition or parents of those children? Yes No If yes, complete the following: Name of Court State Case No. Type of Court Case 17. Optional: I am alleging, under oath, that my or my child/ren222s health, safety, or liberty would be jeopardized by the disclosure of identifying information set forth in this Affidavit. To support my allegation, I state as follows: Note: In domestic violence actions under RSA 173-B, the whereabouts of the plaintiff shall not be released except by court order. 18. Your petitioner asks that the parental rights of over be terminated and that custody or guardianship of be transferred to of I acknowledge that I have a continuing duty to inform the court of any court action in this or any other state that could affect the child/ren in this case. I swear or affirm that the foregoing information is true and correct to the best of my knowledge. Date Petitioner Signature Date Petitioner Signature American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Termination of Parental Rights of Case Number: PETITION FOR TERMINATION OF PARENTAL RIGHTS NHJB-2188-F (03/26/2019) Page 5 of 5 State of , County of This instrument was acknowledged before me on by My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title To be completed by Division for Children, Youth and Families ONLY. Court Name Case Number Attorney representing parents Telephone Address DCYF Attorney Telephone Address DCYF Social Worker Telephone Address Child's GAL Telephone Address American LegalNet, Inc. www.FormsWorkFlow.com