<% 'select case Request.ServerVariables("Server_Name") 'case "dispostings.dshs.wa.gov" %> <% 'case else %> <% 'end select %>

IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON

IN AND FOR THE COUNTY OF KITSAP

JUVENILE DIVISION

Dependency of )
) NO.
)
) DEPENDENCY PETITION
)
B.D.: )
)

I. BASIS

I represent to the court the following:

1.1 Information about the child:

Name: Age: Sex:

Date of Birth:

Address:

1.2 The child:

( ) is an Indian child as defined in 25 U.S.C. 1903(4). The Indian Child Welfare Act, 25 U.S.C. 1901 et seq., applies to this proceeding.

See attached Addendum to Petition.

( ) may be an Indian child as defined in 25 U.S.C. 1903(4). The Indian Child Welfare Act may apply to this proceeding.

See attached Addendum to Petition.

( ) is or may be a Canadian Indian child or an unenrolled Indian child as defined in WAC 388-70-091 (2) and (3). The Indian Child Welfare

Act does not apply to this proceeding.

( ) is not an Indian. The Indian Child Welfare Act does not apply to this proceeding.

1.3 Known information about the parent(s), guardian or custodian:

(a) Name of father:

Address:

(b) Name of Mother:

Address:

(d) Name of guardian/custodian:

Address:

1.4 The child is dependent according to RCW 13.34.030 (5) in that:

( ) (a) the child has been abandoned, that is, the child's parent, guardian or other custodian has evidenced either by statement

or conduct, an intention to forego, for an extended period, all parental rights or responsibilities despite an ability

to do so;

( ) (b) the child is abused or neglected as defined in Chapter 26.44 RCW;

( ) (c) the child has no parent, guardian or custodian capable of adequately caring for the child, such that the child is in

circumstances which constitute a danger of substantial damage to the child's psychological or physical development;

1.5 The allegation of dependency is based on the following facts:

II. RELIEF REQUESTED

I request that the court inquire into this matter and make such order as the court finds

to be in the best interest of the child and justice.

Date:

Petitioner

DCFS Supervisor

Assistant Attorney General, WSBA#

----

III. VERIFICATION

STATE OF WASHINGTON )

)

COUNTY OF KITSAP )

The undersigned on oath states that:

3.1 I am the petitioner in this matter: , DCFS

3.2 I have read the above petition, know its contents, and believe it to be true.

Petitioner

Type or Print Name

Mailing Address

Telephone Number

SUBSCRIBED AND SWORN TO this day of , 2003.

NOTARY PUBLIC in and for the State of Washington

My commission expires:

IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON

IN AND FOR THE COUNTY OF KITSAP

JUVENILE DEPARTMENT

IN RE THE DEPENDENCY OF: ) NO.

)

) MOTION AND AFFIDAVIT FOR

) ORDER TO TAKE CHILD INTO CUSTODY D.O.B.

) PURSUANT TO RCW 13.34.050 ______________________________)

I. MOTION

COMES NOW the undersigned and moves the court for an order to take the above-named child

into custody based on the following affidavit.

DATED: _______________________ ____________________________________

DEPT. OF SOCIAL & HEALTH SERVICES, DIVISION OF CHILDREN & FAMILY SERVICES

II. AFFIDAVIT

STATE OF WASHINGTON ) :

County of Kitsap )

The undersigned being first duly sworn upon, deposes and says:

1. My relationship to the child is: DCFS social worker.

2. A petition has been filed with the juvenile court alleging that the child is dependent,

and the allegations in the petition are incorporated herein by reference.

3. I believe that the child's health, safety and welfare will be seriously endangered if

the child is not taken into custody as shown in the Dependency Petition filed herewith

and incorporated herein by reference.

________________________________________

DCFS SOCIAL WORKER

S UBSCRIBED AND SWORN to before me this ____ day of ___________, 2003.

_ _______________________________________

N OTARY PUBLIC in and for the State of Washington

C ommission Expires:_____________________

P resented By:

_________________________________________

ASSISTANT ATTORNEY GENERAL, WSBA#

IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON

IN AND FOR THE COUNTY OF KITSAP

JUVENILE DEPARTMENT

IN RE THE DEPENDENCY OF: ) NO.

)

) ORDER TO TAKE CHILD INTO

D.O.B. ) CUSTODY AND PLACEMENT IN

) SHELTER CARE

Minor Child(ren) )

_____________________________)

I. BASIS

THE COURT having considered a motion, statement and declaration requesting an order to take

the above- named child into custody.

II. FINDINGS

The court FINDS that:

2.1 A petition has been filed with the Court alleging that the child is dependent pursuant to

RCW 13.34.030(5).

2.2 It is currently contrary to the welfare of the child to remain in the child's home. The

petition and/or supporting declarations and affidavits establish reasonable grounds to

believe that the child is dependent and the child's health, safety, and welfare will be

seriously endangered if not taken into custody.

ORDER TAKING CHILD INTO CUSTODY 1 ATTORNEY GENERAL OF WASHINGTON

AND PLACEMENT IN SHELTER CARE 1019 Pacific Avenue South, 3rd Floor

Tacoma, WA 98402-4411

(253) 593-5243

2.3 The petitioner has demonstrated that there is a risk of imminent harm to the child in the child's

home. The assessment of risk by petitioner constitutes reasonable efforts to prevent or eliminate

the need for removal of the child from the child's home and:

[ ] due to the risk of imminent harm to the child, there are no reasonably available services that can be provided to the parent(s) to maintain the child in the child's home at this time. [ ] services previously offered or provided to the parent(s) have been unable to remedy the unsafe conditions in the home; [ ] there is no parent, guardian or legal custodian known to petitioner at this time who is available to take custody of the child; and/or

[ ]___________________________________________________________________

III. ORDER

IT IS ORDERED that:

3.1 The above-named minor child shall be taken into custody by a law enforcement officer, probation

counselor, or child protective services worker, and placed in a facility licensed pursuant to

RCW 74.15.030, or in a home not required to be licensed pursuant to that section, under the

supervision of DSHS.

3.2 The supervising agency may authorize evaluations of the child's physical or emotional condition,

routine medical and dental examination and care, and all necessary emergency care.

3.3 The child shall remain in shelter care for not more than 72 hours from the time the child is

taken into custody, excluding Saturdays, Sundays and holidays, unless an order authorizing

continued shelter is entered.

DATED:________________ _____________________________________________

JUDGE/COMMISSIONER

PRESENTED BY:

____________________________________________

ASSISTANT ATTORNEY GENERAL, WSBA#

ORDER TAKING CHILD INTO CUSTODY 2 ATTORNEY GENERAL OF WASHINGTON

AND PLACEMENT IN SHELTER CARE 1019 Pacific Avenue South, 3rd Floor

Tacoma, WA 98402-4411

(253) 593-5243

IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON

IN AND FOR THE COUNTY OF KITSAP

JUVENILE DEPARTMENT

DEPENDENCY OF: ) NO.

)

) NOTICE & SUMMONS/ORDER

) (DEPENDENCY/GUARDIANSHIP)

D.O.B. )

STATE OF WASHINGTON TO:

Name:

Address:

I. NOTICE OF HEARING 1.1 You are notified that a petition, a copy of which is attached, was filed

with this Court alleging that:

[ ] the above-named child is dependent. A dependency petition begins a process which, if

the child is found dependent, could result in substantial restriction or permanent

loss of your parental rights.

[ ] guardianship should be established for the above-named child. A guardianship petition,

if granted, could result in substantial restrictions of your parental rights.

1.2 A hearing will be held:

On at (Date) (Time)

Address: KITSAP COUNTY SUPERIOR COURT

1338 SW Old Clifton Road

PORT ORCHARD, WA 98366

1.3 The purpose of the hearing is to hear and consider evidence on the petition.

1.4 If you do not appear THE COURT MAY ENTER AN ORDER IN YOUR ABSENCE:

[ ] establishing Dependency;

[ ] establishing Guardianship.

1.5 If the child is placed in out-of-home care, you may be held responsible for the support

of the child.

II. SUMMONS/ORDER TO APPEAR

2.1 [ ] YOU ARE SUMMONED AND REQUIRED to appear at the hearing on the date, time, and place

indicated.

2.2 [ ] YOU ARE ORDERED AND REQUIRED as the parent, guardian or custodian having custody or

control of the child to bring the child to the hearing.

NOTICE

VIOLATION OF THIS ORDER OR SUMMONS IS SUBJECT TO A

PROCEEDING FOR CONTEMPT OF COURT PURSUANT TO RCW 13.34.070.

III. ADVICE OF RIGHTS

3.1 You have important legal rights, and you must take steps to protect your interest.

3.2 You have the right to a fact finding hearing before a judge. At the hearing, you have the right to speak on your own behalf, to introduce evidence, to examine witnesses, and to receive a decision based solely on the evidence presented to the judge. You should attend this hearing.

3.3 You have the right to be represented by a lawyer. If you cannot afford a lawyer, you have the right to request a public defender. If you qualify, a lawyer will be appointed by the Court to represent you.

3.4 Your lawyer can look at the social and legal files in your case, talk to the agency social worker, tell you about the law, help you understand your rights and help you at hearings.

3.5 If you wish to have a lawyer appointed contact JUVENILE COURT SERVICES:

Address: JUVENILE COURT SERVICES

1338 S.W. OLD CLIFTON ROAD

PORT ORCHARD, WA 98366

Phone: (360) 876-7055

DATED this day of , 2003.

By the direction of the Honorable

DAVID W. PETERSON, CLERK

By:______________________________

Deputy Clerk

IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON

IN AND FOR THE COUNTY OF KITSAP

JUVENILE DEPARTMENT

DEPENDENCY OF: ) NO.

)

) NOTICE & SUMMONS/ORDER

) (DEPENDENCY/GUARDIANSHIP)

D.O.B. 0000 )

STATE OF WASHINGTON TO:

Name:

Address:

I. NOTICE OF HEARING

1.1 You are notified that a petition, a copy of which is attached, was filed with this

Court alleging that:

[ ] the above-named child is dependent. A dependency petition begins a process which,

if the child is found dependent, could result in substantial restriction or permanent

loss of your parental rights.

[ ] guardianship should be established for the above-named child. A guardianship petition,

if granted, could result in substantial restrictions of your parental rights.

1.2 A hearing will be held:

On at (Date) (Time)

Address: KITSAP COUNTY SUPERIOR COURT

1338 SW Old Clifton Road

PORT ORCHARD, WA 98366

1.3 The purpose of the hearing is to hear and consider evidence on the petition.

1.4 If you do not appear THE COURT MAY ENTER AN ORDER IN YOUR ABSENCE:

[ ] establishing Dependency;

[ ] establishing Guardianship.

1.5 If the child is placed in out-of-home care, you may be held responsible for the support

of the child.

II. SUMMONS/ORDER TO APPEAR

2.1 [ ] YOU ARE SUMMONED AND REQUIRED to appear at the hearing on the date, time, and

place indicated.

2.2 [ ] YOU ARE ORDERED AND REQUIRED as the parent, guardian or custodian having custody

or control of the child to bring the child to the hearing.

NOTICE

VIOLATION OF THIS ORDER OR SUMMONS IS SUBJECT TO A

PROCEEDING FOR CONTEMPT OF COURT PURSUANT TO RCW 13.34.070.

III. ADVICE OF RIGHTS

3.1 You have important legal rights, and you must take steps to protect your interest.

3.2 You have the right to a fact finding hearing before a judge. At the hearing, you have the

right to speak on your own behalf, to introduce evidence, to examine witnesses, and to

receive a decision based solely on the evidence presented to the judge. You should attend

this hearing.

3.3 You have the right to be represented by a lawyer. If you cannot afford a lawyer, you have

the right to request a public defender. If you qualify, a lawyer will be appointed by the

Court to represent you.

3.4 Your lawyer can look at the social and legal files in your case, talk to the agency social

worker, tell you about the law, help you understand your rights and help you at hearings.

3.5 If you wish to have a lawyer appointed contact JUVENILE COURT SERVICES:

Address: JUVENILE COURT SERVICES

1338 S.W. OLD CLIFTON ROAD

PORT ORCHARD, WA 98366

Phone: (360) 876-7055

DATED this day of , 2003.

By the direction of the Honorable

DAVID W. PETERSON, CLERK

By: _____________________________

Deputy Clerk

SUPERIOR COURT OF THE STATE OF WASHINGTON

COUNTY OF KITSAP

JUVENILE DIVISION

In Re the Welfare of: )

) NO.:

) DECLARATION OF SERVICE/RETURN OF

) SERVICE

_____________________________ )

I CERTIFY OR DECLARE:

1. I am over the age of 18 years and I am not a party to this action or I am authorized

to perfect service pursuant to RCW 13.34.070(9).

2. I served with the following documents:

Dependency Petition

Guardianship Petition

Petition for Termination of Parent-Child Relationship

Notice and Summons/Order (Dependency/Guardianship/Termination of Parent/Child Relationship)

[See attached copy of Notice and Summons]

Motion and Order to Take Child into Custody

Order Authorizing Continued Shelter Care

Order Authorizing Routine Medical Care

Parent's Guide to CPS (Handbook)

Notification for Department of Assigned Counsel Representation

Temporary Shelter Care Notification

Order Setting Case Schedule: Dependency

Other:

3. The date, time and place of service were:

Date: Time: a.m./p.m.

Address:

4. Service was made pursuant to CR4(d), RCW 13.34.070 and RCW 13.34.080:

By personal service on to the person named in Paragraph 2 above.

By delivery to a person of suitable age and discretion residing at the

Respondent's usual abode

By publication as provided in RCW 4.28.100 and RCW 13.34.080

By mailing two copies postage prepaid to the above person named in paragraph 2

above. One copy was mailed by ordinary first class mail, the other copy was sent by

certified mail return receipt requested. [Attach return receipt below]

The copies were mailed on:

5. Other:

I declare or certify under perjury under the laws of the State of Washington that the

foregoing is true and correct.

______________________ _______________________________________________

Date and Place Signature

______________________________________________

Print Name

SUPERIOR COURT OF THE STATE OF WASHINGTON

COUNTY OF KITSAP

JUVENILE DIVISION

In Re the Welfare of: )

) NO.:

) DECLARATION OF SERVICE/RETURN OF

) SERVICE

_____________________________ )

I CERTIFY OR DECLARE:

1. I am over the age of 18 years and I am not a party to this action or I am authorized to perfect service pursuant to RCW 13.34.070(9).

2. I served with the following documents:

Dependency Petition

Guardianship Petition

Petition for Termination of Parent-Child Relationship

Notice and Summons/Order (Dependency/Guardianship/Termination of Parent/Child Relationship)

[See attached copy of Notice and Summons]

Motion and Order to Take Child into Custody

Order Authorizing Continued Shelter Care

Order Authorizing Routine Medical Care

Parent's Guide to CPS (Handbook)

Notification for Department of Assigned Counsel Representation

Temporary Shelter Care Notification

Order Setting Case Schedule: Dependency

Other:

3. The date, time and place of service were:

Date: Time: a.m./p.m.

Address:

4. Service was made pursuant to CR4(d), RCW 13.34.070 and RCW 13.34.080:

By personal service on to the person named in Paragraph 2 above.

By delivery to a person of suitable age and discretion residing at the

Respondents' usual abode

By publication as provided in RCW 4.28.100 and RCW 13.34.080

By mailing two copies postage prepaid to the above person named in paragraph 2

above. One copy was mailed by ordinary first class mail, the other copy was sent

by certified mail return receipt requested. [Attach return receipt below]

The copies were mailed on:

5. Other:

I declare or certify under perjury under the laws of the State of Washington that the

foregoing is true and correct.

______________________ _______________________________________________

Date and Place Signature

______________________________________________

Print Name