Fillable Form Dc-511 - Petition printable pdf download

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PETITION

Case No.

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Commonwealth of Virginia

VA. CODE §§ 16.1-262; 16.1-263

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DATE OF HEARING

Juvenile and Domestic Relations District Court

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In re a Child under eighteen years of age

CHILD’S NAME

SSN:

DATE OF BIRTH

AGE

SEX

ACE

M.F.

CHILD’S ADDRESS

TELEPHONE NO.

FATHER’S NAME

SSN

DATE OF BIRTH

TELEPHONE NO.

FATHER’S ADDRESS

MOTHER’S NAME

SSN

DATE OF BIRTH

TELEPHONE NO.

MOTHER’S ADDRESS

GUARDIAN/LEGAL CUSTODIAN OR PERSON IN LOCO PARENTIS NAME AND ADDRESS

TELEPHONE NO

GUARDIAN’S /LEGAL CUSTODIAN OR PERSON IN LOCO PARENTIS RELATIONSHIP TO CHILD

10.

OTHER(S) NAME AND ADDRESS

TELEPHONE NO.

11.

[ ]

12. Child held in CUSTODY

Yes

13. Place of Detention or Shelter Care

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14. Date and Time Taken into Custody

13. Date and Time Placed in Detention or Shelter Care

_____ / _____ / _____

_____: _____ _____ m.

______ / ______ / ______

_____ : _____ _____ m.

15. The above information is not known to the petitioner: No(s).

I, the undersigned petitioner, state under oath to the best of my knowledge, that the above-named child is within the purview of the Juvenile and

Domestic Relations District Court Law in that, within this city/county, the child:

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(FOR ADMINISTRATIVE USE ONLY IN DELINQUENCY CASES) Virginia Crime Code:

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WHEREFORE, the Petitioner requests that the child and the persons having his or her custody and control be summoned to appear before this Court,

and that this Court enter such orders and judgments as the Court deems fit and proper in accordance with the law and which will serve the purpose

and intent of the Juvenile and Domestic Relations District Court Law.

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____________________________________________

DATE

PETITIONER’S NAME (PRINT OR TYPE)

PETITIONER’S SIGNATURE

PETITIONER’S ADDRESS AND TELEPHONE NUMBER (COURT COPY ONLY)

Sworn/affirmed and signed before me on

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Title:

Signature:

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_________________________________________________________

Filed by:

______________________________________________________________

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[ ]

INTAKE OFFICER

ATTORNEY

DATE

FOR NOTARY PUBLIC’S USE ONLY: