District No.

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

.......... Applicant

of ........

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

of .........

WHEREAS the above-named child, who *is *appears to be aged .... years, having been born *(so far as has been ascertained) on the ... day of ...... 19... *resides *has been found at ....... in the area of the applicant health board and in said court district,

AND WHEREAS the applicant believes that—

*(the child has been or is being assaulted, ill-treated, neglected, sexually abused)

*(the child's health, development or welfare has been or is being avoidably impaired or neglected,)

*(the child's health, development or welfare is likely to be avoidably impaired or neglected,)

and that the child requires care or protection which he/she is unlikely to receive unless the Court makes an order under section 18 of the above-mentioned Act,

TAKE NOTICE that the applicant will apply at the sitting of the District Court to be held at ...... on the ... day of ...... 19... at ...... a.m./p.m. for a care order with respect to the said child under section 18 (7) of the Act *(and for an order under section 18 (7) of the Act requiring a contribution towards the cost of maintaining the child).

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

Signed ..........

Solicitor for Applicant

To ..................

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

the above-named respondent.

* Delete words inapplicable