District No.

In the matter of .................... a child

................... Applicant

of .......................

................. Respondent

of ................................

THE INFORMATION of ...............................

of .........................

who says on oath—

*(I am the applicant herein,) *(I have been authorised by the ................ Health Board to make this application.)

(I say that the above-named child ............... is in the care of the ................ Health Board, and that on the ....... day of ......., 19..., without lawful authority, he/she was—

*(removed from the custody of the board.)

*(removed from the custody of ............. of ............... who was taking care of the child on behalf of the board.)

*[prevented from returning to the custody *(of the board) *(of ............. of ................ who was taking care of the child on behalf of the board) at the end of a period of leave.]

I believe that the child is in the † ................... at ..................... in the said court district and I hereby apply for the issue of a warrant under section 46 (6) of the above-mentioned Act to search therein for the child.

Dated this ...... day of ...... 19 ........

Signed ..................

Informant

Sworn before me this ..... day of ....... 19 ..... at ..................

Signed . .........................

Judge of the Children Court

*(assigned to the said district)

* Delete words inapplicable
† Name the house or other place as set out in section 46 (6) of the Act.