CYPF No:
In the District Court at [place]
Particulars of child or young person the application is about
This information sheet accompanies application(s) about [full name of child or young person the application is about].
*Home address:
*Work address:
*Contact telephone number(s): [home, work]
Age:
Date of birth:
Cultural or ethnic identity:
The child (or young person) the application is about is living with the following person(s):
Full name:
*Home address:
*Work address:
*Contact telephone number(s): [home, work]
Relationship or status in relation to the child (or young person):
The child (or young person) has lived with that person for [state period].
The living parent(s) of the child (or young person) are as follows:
Full name:
*Home address:
*Work address:
*Contact telephone number(s): [home, work]
The guardians of the child (or young person) are as follows:
Full name:
*Home address:
*Work address:
*Contact telephone number(s): [home, work]
| *These details may be omitted from copy to be served with application. |
The child (or young person) is in the legal custody of [where the child or young person is in the legal custody of the chief executive or an Iwi Authority or a Cultural Authority or the Director of a Child and Family Support Service or the controlling authority of a residential disability care institution (within the meaning of section 58(4) of the Health and Disability Services (Safety) Act 2001), state the name and address of the person or organisation having legal custody].
The child (or young person) is in that custody by reason of [state the legal authority for that custody, eg, place of safety warrant under section 39 of the Act, and give details of that legal authority, including the date of commencement, and, if granted by a court, the location of the court and the file number of the proceedings (if known)].
The following court orders are in force in respect of the child (or young person): [state the nature of the order, the date on which it was made, the court that made the order, the location of that court, and the file number of the proceedings (if known)].
*The barrister or solicitor representing the child (or young person) in these proceedings is [full name], of [address].
Previous applications: [give the file number of, or sufficient information to identify, any previous applications relating to the child or young person the application is about, and the courts where those applications were filed].
Nature of applications
The applications are:
1
2
A family group conference *has/*has not been held in respect of the matter that forms the ground of the application(s).
A medical examination of the child or young person *has/*has not been carried out under section 50 or section 53 of the Act.
Particulars of applicant
The applicant is [full name], of [address], [occupation].
Home address:
Work address:
Contact telephone number(s): [home, work]
Relationship or status in relation to the child or young person:
Capacity in which the application is made:
Address for service
The accompanying applications are filed by [specify], whose address for service* is at [address].
| *This address must be a place in New Zealand where any document may be left for the applicant. It may not be the address of a post office box, document exchange, or rural delivery. |
For court use:
Date stamp:
Schedule 1 form CYPF 5: amended, on 1 October 2002, by section 58(3) of the Health and Disability Services (Safety) Act 2001 (2001 No 93).
Schedule 1 form CYPF 5: amended, on 1 October 1999, pursuant to section 11(3) of the Department of Child, Youth and Family Services Act 1999 (1999 No 82).