IN THE CIRCUIT COURT OF THE __________________ JUDICIAL CIRCUIT IN AND FOR ________________ COUNTY, FLORIDA JUVENILE DIVISION ) ) ) ) ) In the Interest of Case No. ______________ a child children AFFIDAVIT AND PETITION FOR PLACEMENT IN SHELTER COMES NOW, the undersigned, who being first duly sworn says: l. On at was/were found within the jurisdiction of this court. .m. the above named minor child(ren) The child(ren) was/were taken into custody by The child(ren) need(s) to be taken into protective custody. Name 2. The name, age, and residence of this/these child(ren) is/are: Birthdate Sex Address 3. The name, relationship to the child(ren), and address of the child(ren)'s parents or other legal custodian(s) is/are: Name Relationship Address 4. The following individuals who were listed in #3 above have been notified in the following manner of the date, time, and location of this hearing: Name Manner Notified 5. There is probable cause that the child(ren) a. has/have been abused, abandoned, or neglected or is/are in imminent danger of illness or injury as a result of abuse, abandonment, or neglect; b. was/were with a parent or legal custodian who has materially violated a condition of placement imposed by the court; c. has/have no parent, legal custodian, or responsible adult relative immediately Shelter Petition {8.960} Revised effective February 19, 2015 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com known and available to provide supervision and care; because ______________ _______________________________________________________________. 6. The provision of appropriate and available services will not eliminate the need for placement of the child(ren) in shelter care because: a. an emergency existed in which the child(ren) could not safely remain in the home; b. the home situation presents a substantial and immediate danger to the child(ren) which cannot be mitigated by the provision of preventive services; c. the child(ren) could not be protected in the home despite the provision of the following services and efforts made by the Department of Children and Family Services to prevent or eliminate the need for placement in shelter care: _______ _______________________________________________________________. d. The child(ren) cannot safely remain at home because there are no preventive services that can ensure the safety of the child(ren). 7. The department has made reasonable efforts to keep the siblings together after the removal from the home. The reasonable efforts of the department were ____________________ ____________________________________________________________________________. a. The children are currently placed together ____________________________. b. A foster home is not available to place the siblings together _______________ ________________________________________________________________. c. It is not in the best interest of the child that all the siblings be placed together in out-of-home care because __________________________________________ _______________________________________________________________. 8. Ongoing visitation or interaction between the siblings ____(list)_____________ __________________________________________________________________________ is a. recommended as follows: ______________________________________ __________________________________________________________________. b. not recommended because visitation or interaction would be contrary to the safety or well-being of ______________(names)_____________________________ because _________________________________________________________. 9. The child(ren) is/are in need of and the petitioner requests the appointment of a guardian ad litem. 10. The petitioner requests that the parents, if able, be ordered pay fees for the care, support, and maintenance of the child(ren) as established by the department under chapter 39, Florida Statutes. 11. The petitioner requests that the parents be ordered to provide to the Department Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Shelter Petition {8.960} Revised effective February 19, 2015 of Children and Families and the Department of Revenue financial information necessary to accurately calculate child support under section 61.30, Florida Statutes, within 28 days of this order. 12. This affidavit and petition is filed in good faith and under oath. WHEREFORE, the affiant requests that this court order that this/these child(ren) be placed in the custody of the department until further order of this court and that the place of such custody shall be: at the discretion of the Department of Children and Families; at the home of a responsible adult relative, , whose address is other: ________________________________________________________________ Moving Party attorney's name address telephone number Florida Bar No. VERIFICATION STATE OF FLORIDA COUNTY OF Before me, the undersigned authority, personally appeared ________________________, who, being sworn, says this affidavit is filed in good faith and on information, knowledge, and belief is true. Sworn to and subscribed before me on (name and title) . NOTICE TO PARENTS/GUARDIANS/LEGAL CUSTODIANS A date and time for an arraignment hearing is normally set at this shelter hearing. If one is not set or if there are questions, you should contact the Juvenile Court Clerk's office at _____________________________________________________. A copy of the Petition for Dependency will be given to you o to your attorney, if you have one. A copy will also be available in the clerk's office. You have a right to have an attorney represent you at this hearing and during the dependency proceedings and an attorney will be appointed for you if you request an attorney and the court finds that you are unable to afford an attorney. If you are a person with a disability who needs any accommodation to Shelter Petition {8.960} Revised effective February 19, 2015 Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com participate in this proceeding, you are entitled, at no cost to you, to the provision of certain assistance. Please contact ______________(name, address, telephone number)______________________ at least 7 days before your scheduled court appearance, or immediately upon receiving this notification if the time before the scheduled appearance is less than 7 days. If you are hearing or voice impaired, call 711. Shelter Petition {8.960} Revised effective February 19, 2015 Page 4 of 4 American Leg