Petition For Termination Of Parental Rights {NHJB-2188-FP}

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 PETITION FOR TERMINATION OF PARENTAL RIGHTS RSA 170-C NOTE: Pursuant to RSA 458-A, you must attach the Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit (Form NHJB-2660-DFPS) to this petition. Your petitioner(s) represents the following: 1. Petitioner Name Petitioner Name Mailing Address Residence Address 2. Attorney Name Mailing Address 3. Petitioner(s) relationship to child: Guardian Legal Custodian Telephone Telephone Telephone Parent Foster Parent Authorized Agency Male Female 4. Child Name Date of Birth Residence Address Place of Birth 5. Birth father name Mailing address Birth mother name Mailing address Date of Birth Date of Birth 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 NHJB-2188-FP (12/01/2010) (formerly AOC-082E-003 and AOC-082E-008) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Termination of Parental Rights of Case Number: PETITION FOR TERMINATION OF PARENTAL RIGHTS 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. 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 child's 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 child's 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 child's other parent, or other persons related by blood or marriage, including a minor child who resided with the defendant. Specify here your factual allegations in support of your petition. 9. 10. NHJB-2188-FP (12/01/2010) (formerly AOC-082E-003 and AOC-082E-008) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Termination of Parental Rights of Case Number: PETITION FOR TERMINATION OF PARENTAL RIGHTS 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. 12. Your petitioner asks that the parental rights of over be terminated and that custody or guardianship of be transferred to of I swear or affirm that the foregoing information is true and correct to the best of my knowledge. Date Petitioner Signature Date Petitioner Signature State of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any , County of by Signature of Notarial Officer / Title To be completed by Division for Children, Youth and Families ONLY. Court Name Attorney representing parents Address DCYF Attorney Address DCYF Social Worker Address Child's GAL Address Telephone Telephone Telephone Case Number Telephone NHJB-2188-FP (12/01/2010) (formerly AOC-082E-003 and AOC-082E-008) Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com