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IN THE JUVENILE COURT OF BEDFORD COUNTY, TENNESSEE

In the Matter of Docket No.


______________

[name], DOB [birthdate]

Child under Eighteen (18) Years of Age

PETITION TO ADJUDICATE DEPENDENCY AND NEGLECT

Pursuant to T.C.A. § 37-1-108, your petitioner respectfully represents to the Court upon
information and belief that:

1. [name], age [age], was born [date] in [city & country]. A photocopy of the child’s birth
certificate and English translation is attached to this Petition.

2. The child has resided in Bedford County, Tennessee since approximately [date]. The child
lives with her paternal uncle, [uncle’s name], residing at [address], Memphis, Tennessee, [ZIP].
[Relation] is a citizen of [country], but works and resides legally in the United States pursuant
to a grant of Temporary Protected Status (TPS). See 8 U.S.C. § 1254a.

3. Said children are dependent and neglected children within the meaning of the law of the
State of Tennessee in that said children are without a parent, guardian, or legal custodian.
T.C.A. § 37-1-102(b)(12)(A).

4. It is in the best interest of said children and the public that this proceeding be brought.

5. The father is [father’s name], [residing at/whereabouts unknown] since [Date], last residing
in [city & country]. The mother is [mother’s name], [residing at/whereabouts unknown] since
[Date], last residing in [city & country].

6. [Facts of Children's residence]Until approximately [date], the children lived with their
paternal grandmother, [grandmother’s name], in [city & country]. Upon information and belief,
no custody or guardianship order awarded [grandmother] custody of the children; the father and
mother simply gave the children to [grandmother] when they left [city] and ended contact with
the remainder of the family in 1996.

7. On [date], [grandmother] executed a notarized document in San Pedro Sula, giving full
custody of the children to [uncle] due to [grandmother]’s age and poor health. According to a
December 2006 written medical evaluation by [doctor] of [city], [grandmother] suffers from
severe Type II diabetes, hypertension, hypercholesterolemia, and paralysis. Copies of these
documents and English translations are attached. [Uncle] is unaware of any family member or
other individual in [country] who is willing or able to assume the care and custody of the
children. On or about [date], [uncle] learned that [grandmother] suffered another stroke or
cerebral hemorrhage, is gravely ill and is possibly near death.

8. The children entered the United States on approximately [date]. They are currently in
proceedings before the U.S. Department of Justice, Memphis Immigration Court, to determine
their immigration status in the United States. As indicated by the attached correspondence, U.S.
Immigration and Customs Enforcement has indicated in writing that it is not required to
specifically consent to this Court’s exercise of jurisdiction over the children.

9. In the event that this Court finds that the children are dependent and neglected, that they are
eligible for long-term foster care due to abandonment, and that it is not in their best interest to
be returned to [country], the children intend to petition U.S. Citizenship and Immigration
Services for Special Immigrant Juvenile Status (SIJS). 8 U.S.C. § 1101(a)(27)(J), 8 C.F.R. §
204.11.

10. Petitioner is not aware of any prior or pending litigation in this or any other jurisdiction
concerning custody of the children. No other person is known who claims the right to physical
custody or visitation with the children. Petitioner would state that since the parents’
whereabouts have been unknown for approximately eleven years, it is not reasonable to make
further attempts at family reunification, and immediate adjudication of their dependency and
neglect and disposition of the children’s legal custody is appropriate.

WHEREFORE, PREMISES CONSIDERED, petitioner prays that the Court make inquiry into
the allegations set forth herein and make such orders as the Court may deem proper and in the best
interest of said children. In particular, petitioner prays:

1. That the children be declared dependents of this Court;

2. That the Court declare the children eligible for long-term foster care due to abuse, neglect,
or abandonment, since reunification with the parents is no longer a viable option. See T.C.A. §
37-1-129;

3. That Petitioner be permitted to serve the Respondent parents with a copy of this Petition
and a Summons by publication, as their whereabouts are unknown;

4. That a Spanish-speaking guardian ad litem or attorney ad litem be appointed for the


children, to be compensated pursuant to T.C.A. § 37-1-150 and applicable rules;

5. That the Court award guardianship of the children to Petitioner [uncle], with authority to
consent to ordinary or necessary medical, surgical, hospital, educational, institutional,
psychiatric or psychological care, subject to further orders of this Court;

6. That the Court declare that it would not be in the children’s best interest to be returned to
their country of nationality, [country]; and

7. That the Court declare that it is in the children’s best interest to remain in the United States.

_________________________________
[uncle’s name, address & telephone]

THOMASON, HENDRIX, HARVEY,


JOHNSON & MITCHELL, PLLC

By: __________________________________
AFFIDAVIT

State of Tennessee )
County of Shelby )

I hereby make oath, under penalty of perjury, that the facts contained in the foregoing Petition
are true and correct to the best of my belief, and that the foregoing was read to me in the Spanish
language before signing.

Yo por la presente hago el juramento, bajo pena del perjurio, que los hechos contenidos en la
Petición que renuncia son verdad y correcto al mejor de mi creencia, y que el renunciar fue leído a mí
en el idioma Español antes de firmar.

SWORN TO this ________ day of February, 2007.

_____________________________________
[uncle], Affiant

Before me personally appeared the petitioner in the foregoing petition, who makes oath that
the statements therein are true to the best of his knowledge, information, and belief.

This ________ day of February, 2007.

______________________________
Notary Public

My Commission Expires:

_______________________________

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