COUNTY[IES] DIVISION

 DOCKET NO.

    TRIAL COURT OF MASSACHUSETTS
       JUVENILE COURT DEPARTMENT

Application for Child Requiring Assistance

 In Re:

POLICE OFFICER/LAW ENFORCEMENT AFFIRMATION

I swear and affirm under the pains and penalties of perjury that I was unable to deliver the child
to:

1.  one of the child's parents, or to the child's guardian or other responsible person known to the
child, or the child's legal custodian including the Department of Children and Families or the
child's foster home upon written promise, without surety, of the person to whose custody the
child is released that such parent, guardian, person or custodian will bring the child to the court
on the next date;

2.  a temporary shelter licensed or approved by the Department of Early Education and Care, a
shelter home approved by a temporary shelter facility licensed or approved by said department
of early education and care or a family foster care home approved by a placement agency
licensed or approved by said department of early education and care;

for the following reason(s): ______________________________________________________
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Date

JV-094  (11/05/2012)

Signature

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