SAMPLE
STATE OF MAINE

DISTRICT COURT
District of ____________________
Docket No. ________________

In Re Child’s first and last name

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CHILD PROTECTION PETITION

Pursuant to 22 MRSA 4032, Friend #1, Friend #2, and Friend #3, bring this petition and in support thereof state the following:
1.

CHILD
_______________________ is the son/daughter of _____________________ and
________________________________, and was born on __________________ in 2.

(town, State).

CHILD’S RESIDENCE
_____________________________ currently resides at ____________________
____________________________________________.

3.

PETITIONERS
The Petitioners’ names, addresses, and relationship to the child are as follows:
a.

Friend #1, Address, relationship (e.g., is his girlfriend’s mother, and has come to know John during the four months of the relationship between him and her daughter).

b.

Friend #2, Address, relationship (e.g., is the live-in partner of Ms. #1, and has come to know John through his periodic presence at the #1 home)

c.

Friend #3, Address, Relationship (e.g., is the sister of Friend #1, and has come to know John through his relationship with Friend #1’s niece)

4.

PARENTS
____________‘s mother resides at _____________________________________.
____________‘s father resides at _____________________________________.
The legal custodian for ______________ is ____________________, who resides at ___________________________________________________.

5.

SUMMARY OF FACTS PETITIONERS BELIEVE CONSTITUTES
JEOPARDY TO THE CHILD’S HEALTH OR WELFARE
[Sample allegations below]
a.

b.

Since that time John has been staying with different friends, and occasionally on the street.

c.

John’s parents have indicated that they do not want him in their home, and that he is a runaway.

d.

6.

On July 23, 2005, John fled from his parents home in __________, Maine and took refuge at the residence of __________________, Friend #1, and her Mother’s partner, Friend #2, in ____________________, Maine.

John is frequently without adequate food, clothing, or shelter, and health care, and is at risk of exploitation by the adults he encounters on the street and in his various living situations.

REASONABLE EFFORTS TO PREVENT REMOVAL OF THE CHILDREN
FROM THE HOME
a.

b.
7.

[Put any contacts with DHHS here. For example “After his arrival at
Jane’s House on July 26, 2005, a report was filed with DHHS. A DHHS worker has yet to contact John.”]
[Describe here any other efforts to get services or other services that are in place.]

NOTICE REGARDING PARENTAL RIGHTS
Failure to appear at court hearing or court conferences regarding this matter may be determined to indicate an intent to abandon your child pursuant to 22 MRSA
4002(1-A). A finding of abandonment may be the basis for removal of a child from your custody and may ultimately lead to termination of your parental rights.

These proceedings could eventually lead to the termination of your parental rights under 22 MRSA 4051-4057.
WHEREFORE the Petitioner requests:
1.

That the Court fix a time for hearing on this petition, and order notice of the hearing to the parents and custodians of the child, the guardian ad litem for the child, and other parties named in the petition.

2.

That, pursuant to 22 MRSA 4005, the Court appoint a guardian ad litem for the child. 3.

That, after an adjudicatory hearing and finding of jeopardy to the child’s health or welfare and after dispositional hearing, the Court issue a final protection order pursuant to 22 MRSA 4035 and 4036, specifically order that:
[List what you are asking the court to order; examples at page 3-4 above]
a.
b.
c.

4.

That, if the child is removed from the custody of a parent, the Court order each parent to pay a reasonable amount of child support.
Respectfully submitted by
[Signatures must be notarized.]