Or. Rev. Stat. § 419B.809
(4) The petition alleging jurisdiction must set forth in ordinary and concise language such of the following facts as are known and indicate any that are not known. The petition shall:
(8) The petition for jurisdiction must be in substantially the following form.
IN THE CIRCUIT COURT
OF THE STATE OF OREGON
FOR ____________ COUNTY
In the Matter of )
) No.
) Petition No.
)
A Child. ) PETITION
TO THE ABOVE-ENTITLED COURT:
Petitioner, whose name appears below, respectfully represents to the Court as follows:
1. The name, age and residence of the above-named child are as follows: (name); (age);
(DOB); (resides at), _______________, Oregon. (Alternative: The name and age of the above-named
child are as follows: ________. The child’s residence is provided in a sealed document because
providing that information would jeopardize the health, safety or liberty of the child or of
a party to the case. ORS 109.767.)
2. The child is within the jurisdiction of the Court by reason of the following facts:
A. _______________
B. _______________
3. Uniform Child Custody Jurisdiction and Enforcement Act information:
A. Child(ren)’s present address: _______________ (Alternative: The child’s present address is
provided in a sealed document because providing that information would jeopardize the
health, safety or liberty of the child or of a party to the case. ORS 109.767.)
B. Places the child(ren) has lived during the previous five years:
C. Names and present addresses of persons with whom child(ren) has lived during that
period:
D. The petitioner has/has not participated as a party or witness or in any other
capacity in any other proceeding concerning the custody of or parenting time or visitation
with the child. Court, case number and date of any child custody determination:
E. Petitioner knows/does not know of any proceeding that could affect the current
proceeding. Court, case number and date of the proceeding:
F. Petitioner knows/does not know of any person who has physical custody of the
child(ren) or claims rights of legal custody, physical custody, parenting time or visitation
with the child(ren). Names and addresses of such persons:
4. The child resides in ___________ County.
5. The name and present address of each parent is as follows:
6. The petition is not filed pursuant to the direction of this Court.
WHEREFORE, petitioner prays this Court to have an investigation made of the circumstances concerning the above-named child and to make such order or orders as are appropriate in the circumstances.
DATED: ____________, 2___.
Petitioner
STATE OF OREGON )
) ss.
County of ______ )
I, ____________, being first duly sworn, on oath or upon affirmation, depose and say that I am the petitioner in the above-entitled proceeding, that I have read the foregoing petition, know the contents thereof, and the same is true as I am informed and believe.
Petitioner
SIGNED AND SWORN to before me on ____________, 2___.
SEAL (Alternate Verification)
STATE OF OREGON )
) ss.
County of ______ )
I, ____________, being first duly sworn, on oath or upon affirmation, depose and say that I am the petitioner in the above-entitled proceeding, that I have read the foregoing petition, know the contents thereof, and the same is true based on my personal knowledge of this matter.
Petitioner
SIGNED AND SWORN to before me on ____________, 2___.
SEAL
______________________________________________________________________________
[2001 c.622 §4]