CHINS Petition {NHJB-2840-DF}

THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) CHINS PETITION 1. Child's name Race (petitioner: check all that apply): Black or African American Ethnicity: Address 2. Father name Address Telephone number (Home) 3. Mother name Address Telephone number (Home) 4. Physical custodian of the Child Address 5. Petitioner name and organization Address Telephone number 6. The petitioner is filing under the following conditions, alleging the following: a. As a school district official or truant officer: Per RSA 169-D:5 I(a) and RSA 169-D:2, II(a) where the child is subject to compulsory school attendance, and is habitually, willfully, and without good and sufficient cause truant from school. All steps in the school district's intervention process under RSA 189:34,II have been followed prior to filing this petition. As a parent, legal guardian, or custodian, school official, or law enforcement officer pursuant to b. RSA 169-D:5,I: Per RSA 169-D:2,II(b) The child habitually runs away from home and places himself or herself or others in unsafe circumstances. Per RSA 169-D:2,II(b) The child repeatedly disregards the reasonable and lawful commands of his or her parents, guardian, or custodian and places himself or herself or others in unsafe circumstances. Per RSA 169-D:2 II(c) The child has exhibited willful repeated or habitual conduct constituting offenses which would be violations under the criminal code of this state if committed by an adult or, if committed by a person 16 years of age or older, would be violations under the motor vehicle code of this state. Per RSA 169-D:2 II(d) The child has severe emotional, cognitive, or other mental health issues who engages in aggressive, fire setting or sexualized behaviors that pose a danger to the child or others, and that a Letter of Consent from the Department of Health and Human Services is attached to this Petition. NHJB-2840-DF (08/01/2015) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com (Gender) M F Date of Birth Asian Unavailable White Other American Indian/Alaskan Native Non-Hispanic Unavailable Native Hawaiian/Other Pacific Islander Hispanic Date of Birth (Work) Date of Birth (Work) Relationship to Child Telephone number Case Name: Case Number: CHINS PETITION 7. Date(s) and time(s) of child's actions alleged to be the basis of this petition 8. Location of the child's alleged actions 9. Details or facts of the child's alleged actions: 10. Voluntary services have been attempted. See attached statement from DCYF. Explain the nature of voluntary services attempted. 11. Voluntary services have not been attempted. See attached statement from DCYF. 12. Court compulsion is necessary for the following reasons: I swear or affirm that the foregoing information is true and correct to the best of my knowledge. 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 ORDER AND NOTICE OF HEARING A hearing will be held on this petition on at a.m./p.m. at the above-noted court and , the parent(s) or other person(s) having custody or control of the child, is/are hereby ordered to appear at the hearing with the child. Date Clerk/Deputy Clerk SEE BACK FOR IMPORTANT INFORMATION AND FINANCIAL OBLIGATIONS NHJB-2840-DF (08/01/2015) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: CHINS PETITION STATEMENT OF RIGHTS AND FINANCIAL OBLIGATIONS You (the petitioned child ) are advised that you have a right to be represented by an attorney, unless you waive or give up that right by signing a waiver. If you desire an attorney, you should hire one before the date set for the hearing. If you are unable to afford an attorney, the Court, at the Initial Appearance, will appoint an attorney to represent you. In the event that you need additional time to obtain an attorney or prepare a response to this petition, application should be made to the Court for an extension of time. You are further advised that you have the right to remain silent and need not make any statements or give any evidence which might show that you have committed the offense stated in the petition. Your silence even in the face of an accusation cannot be used against you. In accordance with RSA 169-D:29, parents and others chargeable by law for the child's support and necessities are required to reimburse the state for the cost of voluntary or court ordered services. The amount that you will be required to reimburse the state will be based on your ability to pay. You have a right, upon written request, to receive a statement from the department of the cost of services incurred in the case to date. Upon our receipt of notice of a proposed service or placement, you must contact your insurance carrier within 48 hours to see if coverage is available to pay for the proposed service or placement and notify the department of the results. If insurance coverage is available, you must cooperate with your insurance carrier and comply with their requirements for direct payment to the provider." NHJB-2840-DF (08/01/2015) Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com