© 2004 Susan Chana Lask All Rights Reserved.

FAMILY COURT OF THE STATE OF NEW YORK

COUNTY OF ____________

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SAM SMITH,

                                                    Petitioner,                                                             Docket No.___________

                -against -

 JANE DOE                                                                                                            APPLICATION FOR JUDICIAL ACTION

                                                    Respondent.

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TO THE FAMILY COURT

The Undersigned respectfully shows that:

1) Applicant is the_______________________________in the above named case.

2) On________________________ the following occurred:

3) That since the occurrence these facts occurred:

4) That by reason of this petition I respectfully request that:

                        (State relief requested)

5) No previous application has been made to any court or judge for the relief requested (except):

WHEREFORE, your applicant prays that the relief requested be granted in record with the provisions of the Family Court Act.

Dated: __________________,2004                         ______________________________________

                                                                                            APPLI CANT

VERIFICATION

State of New York   )

                                )ss.:

County of _______  )

_________________________above named, being duly sworn, deposes and says that he is the petitioner in the within action; that he has read the contents of the foregoing petition; and that the same is true to his own knowledge.

Sworn to before me

__________________ 2004 ____________________________

                                                  APPLICANT

____________________

                                                    COURT ASSISTANT

© 2004 Susan Chana Lask All Rights Reserved.