Sample Application Cover Letter
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2JV-210
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number and mailing address):
FOR COURT USE ONLY
To keep other people from
seeing what you entered on
your form, please press the
Clear This Form button at the
TELEPHONE NO. (Optional):
FAX NO. (Optional):
end of the form when finished.
E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
CHILD'S NAME:
CASE NUMBER:
APPLICATION TO COMMENCE PROCEEDINGS BY AFFIDAVIT
AND DECISION BY SOCIAL WORKER
(Welf. & Inst. Code, § 329)
To the social worker or social services agency of (specify county):
1. I allege that the child described below is being abused or neglected or at risk of abuse or neglect as defined in Welfare and
Institutions Code section 300. I request that the social worker or agency immediately begin proceedings in the juvenile court on
behalf of the child described below.
2. My name and address:
3. My relationship to the child described below (specify):
4. I am providing the following information about the child.
a. Child's name:
b. Age:
c. Date of birth:
d. Sex:
e. Mother's name:
f. Mother's address:
g. Father's name:
h. Father's address:
i. Other (state name, address, and relationship to child):
5. The child described in item 4 above
a.
resides within this county.
b.
was in this county at the time of the facts alleged below.
6. Facts in support (state supporting facts concisely and include all known and relevant dates, times, names, and addresses. Attach
separate pages as necessary):
See attachment 6. Number of pages attached:
7. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF APPLICANT)
Page 1 of 2
APPLICATION TO COMMENCE PROCEEDINGS BY AFFIDAVIT
Form Approved for Optional Use
Welfare and Institutions Code, § 329
Judicial Council of California
AND DECISION BY SOCIAL WORKER
JV-210 [Rev. July 1, 2010]
(Welf. & Inst. Code, § 329)
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