Oregon Revised Statutes Human Services; Juvenile Code; Corrections § 419B.809

IN THE CIRCUIT COURT

OF THE STATE OF OREGON

FOR ______________ COUNTY

In the Matter of

)

)

No.

)

Petition No.

A Child.

)

PETITION

TO THE ABOVE-ENTITLED COURT:

Petitioner, whose name appears below, respectfully represents to the Court as follows:

1.

The name, age and residence of the above-named child are as follows: (name); (age); (DOB); (resides at), ______________________, Oregon. (Alternative: The name and age of the above-named child are as follows: ___________. The child's residence is provided in a sealed document because providing that information would jeopardize the health, safety or liberty of the child or of a party to the case. ORS 109.767.)

2.

The child is within the jurisdiction of the Court by reason of the following facts:

A.

________________________

B.

________________________

3.

Uniform Child Custody Jurisdiction and Enforcement Act information:

A.

Child(ren)'s present address: ________________________ (Alternative: The child's present address is provided in a sealed document because providing that information would jeopardize the health, safety or liberty of the child or of a party to the case. ORS 109.767.)

B.

Places the child(ren) has lived during the previous five years:

________________________

________________________

C.

Names and present addresses of persons with whom child(ren) has lived during that period:

________________________

________________________

D.

The petitioner has/has not participated as a party or witness or in any other capacity in any other proceeding concerning the custody of or parenting time or visitation with the child. Court, case number and date of any child custody determination:

________________________

E.

Petitioner knows/does not know of any proceeding that could affect the current proceeding. Court, case number and date of the proceeding:

________________________

F.

Petitioner knows/does not know of any person who has physical custody of the child(ren) or claims rights of legal custody, physical custody, parenting time or visitation with the child(ren). Names and addresses of such persons:

________________________

4.

The child resides in _________________ County.

5.

The name and present address of each parent is as follows:

________________________

6.

The petition is not filed pursuant to the direction of this Court.

  WHEREFORE, petitioner prays this Court to have an investigation made of the circumstances concerning the above-named child and to make such order or orders as are appropriate in the circumstances.

      DATED: ___________________, 2______.

_________________________________________________

STATE OF OREGON

)

)

ss.

County of _________

)

  I, __________________, being first duly sworn, on oath or upon affirmation, depose and say that I am the petitioner in the above-entitled proceeding, that I have read the foregoing petition, know the contents thereof, and the same is true as I am informed and believe.

_________________________________________________

  SIGNED AND SWORN to before me on __________________, 2______.

____________________________

SEAL (Alternate Verification)

STATE OF OREGON

)

)

ss.

County of _________

)

  I, __________________, being first duly sworn, on oath or upon affirmation, depose and say that I am the petitioner in the above-entitled proceeding, that I have read the foregoing petition, know the contents thereof, and the same is true based on my personal knowledge of this matter.

_________________________________________________

  SIGNED AND SWORN to before me on __________________, 2______.

____________________________

SEAL