IN THE DISTRICT COURT OF ________________________ COUNTY STATE OF OKLAHOMA JUVENILE DIVISION IN THE MATTER OF: DOB: _______________ DOB: _______________ DOB: _______________ DOB: _______________ DOB: _______________ DOB: _______________ ) ) ) ) ) ) ) JD- _____________________ Date: __________________ Judge: _________________ Alleged Deprived Child(ren). ORDER TO TAKE MINOR CHILD(REN) INTO EMERGENCY CUSTODY NOW, on the ______ day of _____________________, 20 _____ the Court, upon consideration of the within and foregoing Application and attached Affidavit and/or the sworn testimony of _______________________________________________ FINDS, ORDERS, ADJUDGES AND DECREES: I. A. The Indian Child Welfare Act does does not apply, or The name of the Tribe is: __________________________________ . B. is unknown. Pursuant to 10A O.S. § 1-4-201(D) an imminent safety threat exists and the continuation of the child(ren) in the child(ren)'s home is contrary to the welfare of the child(ren), to wit: ______________________________________________________________________________ __________________________________________________________________________________________________ AND Reasonable and/or active efforts have been made to prevent the removal of the child(ren) from the home, and have failed, to wit: _________________________________________ __________________________________________________________________________________________________ OR An absence of efforts to prevent the removal of the child(ren) from the home of the child(ren) is reasonable because the removal is due to an emergency and is for the purpose of providing for the safety and welfare of the child(ren), to wit: ______________ _________________________________________________________________________________________________. All named child(ren) OR The following child(ren): Child: _______________________________________ Child: _______________________________________ Child: _______________________________________ Child: _______________________________________ Child: _______________________________________ Child: _______________________________________ Order to take Minor Child(ren) into Emergency Custody OK-J-UO-0001 Version 1.1.16.2 DOB: _______________________ DOB: _______________________ DOB: _______________________ DOB: _______________________ DOB: _______________________ DOB: _______________________ Page 1 of 2 OCIS Docket Code: OEC American LegalNet, Inc. www.FormsWorkFlow.com II. The child(ren) above named and as described in the Application are hereby committed to the EMERGENCY CUSTODY of the Department of Human Services for the purpose of care and protection; that said minor child(ren) shall be taken into custody by any law enforcement officer, and the said child(ren) shall be taken to ___________________________, or such other appropriate placement as the Department of Human Services shall determine. Further, the Department of Human Services may consent to any routine, diagnostic or emergency medical care or treatment as may be necessary for the health, safety, and welfare of the child(ren). This matter is set for Emergency Custody Hearing on the _______ day of _____________________, 20_____ at _______________ o'clock ______.M., at ___________________________, before Judge __________________________ at which time the Court will determine if said child(ren) shall remain in the emergency custody of the Department of Human Services or be released to a parent, guardian, legal custodian, or other responsible person pending further proceedings. Other: III. IV. ___________________________________________ JUDGE OF THE DISTRICT COURT Order to take Minor Child(ren) into Emergency Custody OK-J-UO-0001 Version 1.1.16.2 Page 2 of 2 OCIS Docket Code: OEC American LegalNet, Inc. www.FormsWorkFlow.com