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COUNTY[IES] DIVISION

           TRIAL COURT OF MASSACHUSETTS
             JUVENILE COURT DEPARTMENT

DOCKET NO.

PETITION FOR GRANDPARENT VISITATION

1.  I/we,

(name(s))

, who reside at

(street and no.)

(city or town)

(state)

(zip code)

request visitation with                                                                                                                                                   .

(child(ren)'s name(s))

2.  I/we  am/are the child(ren)'s:

paternal grandparent(s).  The child(ren)'s father's name is:

maternal grandparent(s).  The child(ren)'s mother's name is:

3.  The child(ren) is/are currently the subject of the following case(s) in this court:
          Care and Protection

          Children in Need of Services

4.  The child(ren) is/are currently in the custody of:
          Department of Children and Families

Other:

5.  I        have        have not  requested visitation from the custodian.

WHEREFORE, I request that the court grant me/us visitation with my/our grandchild(ren).

Signed under the pains and penalties of perjury.

_______________________________________
(Petitioner's Signature/ Grandparent No. 1)

_______________________________________

(Attorney's Signature (if applicable))

_______________________________________
(Petitioner's Signature/ Grandparent No. 2)

_______________________________________

(Date)

(Telephone No.)

(BBO No.)

_______________________________________
(Date)

FOR COURT USE ONLY

ORDER
After a determination of what is in the best interest of the child(ren) by considering the goal of the service plan and
the relationship between the grandparent(s) and the child(ren)'s parent(s) or legal guardian(s), the within petition is
hereby:
                        ______________________________________________________________________________
     ALLOWED

__________________________________________________________________________________________

__________________________________________________________________________________________

_______________________________________

(Date)

_______________________________________
(Justice)

     DENIED

JV-53 (07/20/2010)

INSTRUCTIONS FOR FILING A PETITION FOR GRANDPARENT VISITATION

A Petition for Grandparent Visitation must be filed in the court where there is an underlying
care and protection and/or CHINS case for the child(ren) you wish to visit.

COMPLETING PETITION:  Type or print the petition.

No. 1:  Fill in your name and address.  You are the petitioner.

Nos. 2-5:  Check off and fill in all that apply.

After you have completed the petition, return it to the Clerk-Magistrate's office of the court
where you are filing your case.  You may mail or bring the completed petition to the Clerk-
Magistrate's office.

NOTICE REQUIREMENTS:

Once the Clerk-Magistrate receives the completed form, the court will set a date for you and
the parties to appear in court for a hearing.  The Clerk-Magistrate's office will mail to you or if
you file the petition in person, hand to you an Order of Notice of the hearing date along with a
copy of your petition.  You must mail or hand deliver to each party on the case the following:

       1)  Copy of the Petition for Grandparent Visitation
       2)  Order of Notice

If you mail a copy of the petition and Order of Notice to the party, you must mail it no later than
ten (10) days prior to the hearing.

If you hand deliver a copy of the petition and Order of Notice to the party, you must deliver it to
the person no later than seven (7) days prior to the hearing.

Do I need an attorney?  You are not required to bring an attorney to the hearing, but you may
do so if you wish.  By law, the court cannot appoint an attorney for you even if you cannot
afford one.

What happens if you cannot come to court on the date of the hearing?  All parties must
come to court on the date the case is scheduled for hearing.  If you cannot come to court on
that date, contact the clerk's office immediately upon receipt of your court date.

JV-53 (07/20/2010)