Sworn to and subscribed before me this day of , 20 STATE OF TENNESSEECOUNTY OF SHELBYBefore me personally appeared the petitioner in the foregoing petition, who makes oath that the statements therein are true to the best of his knowledge, information and belief. AFFIDAVIT IN THE JUVENILE COURT OF MEMPHIS AND SHELBY COUNTY, TENNESSEEIN THE MATTER OFA child under 18 years of ageDocket Number PETITIONTo the Honorable Dan H. Michael, Judge of the Juvenile Court of Memphis and Shelby County, Tennessee:Your petitioner respectfully represents to the Court on information and belief that: þ 1. þ Said child is a ward of this Court in custody of the Tennessee Department of Children's Services. A home placement of said child was made on or about , 20 , and said child has violated the conditions of home placement in that said child did on or about , 20 , in Shelby County, Tennessee, commit act, to wit, þ 2. þ It is in the best interest of said child and the public that this proceeding be brought. þ 3. þ Said child is in need of further treatment or rehabilitation. þ 4. þ The father is , residing at . þ 5. þ The mother is , residing at . þ 6. þ The child is/has been in the care and control of , residing at . PetitionerAddressPetitionerJANIS FULLILOVE, Clerk of CourtBy D. C.JC-001A09/01/2018REV A American LegalNet, Inc. www.FormsWorkFlow.com