PT For Rev of Out-of-Home Placement (PTDDP) - Page 1 of 3 WPF JU 12.0100 (07/2018) - JuCR 3.3; RCW 13.34.270(1),(2); RCW 74.13.350 Superior Court of Washington County of Juvenile Court In Re the Welfare of: D.O.B.: No: Petition for Review of Out-of-Home Placement (PTDDP) I. Basis I represent to the court the following: 1.1 Child in Out-of-Home Placement: male female Name Date of Birth Home Address 1.2 Identification of the Parents or Legal Guardians who Agreed to the Child222s Placement in Out-of-Home Care: Mother Father presumed alleged Name 1 2 Date of Birth Marital status single married other single married other Driver222s License or Identicard (# and State) Home Address Father presumed alleged Custodian/Legal Guardian Name 3 4 Date of Birth Marital status single married other Driver222s License or Identicard (# and State) Home Address FOR OFFICIAL USE ONLY Juv. Ref. No: American LegalNet, Inc. www.FormsWorkFlow.com PT For Rev of Out-of-Home Placement (PTDDP) - Page 2 of 3 WPF JU 12.0100 (07/2018) - JuCR 3.3; RCW 13.34.270(1),(2); RCW 74.13.350 1.3 Identification of Parents who are not Parties to the Out-of-Home Placement Agreement: Mother Father presumed alleged Name 1 2 Date of Birth Marital status single married other single married other Driver222s License or Identicard (# and State) Home Address 1.4 Jurisdiction: The child is located or is residing within this county. The child has a developmental disability as defined in RCW 71A.10.020. The child has been placed in out-of-home care pursuant to RCW 74.13.350. 1.5 Child222s Indian status: Based upon the following, the petitioner does not have reason to know the child is an Indian child as defined in RCW 13.38.040 and 25 U.S.C. 247 1903(4), and the Federal and Washington State Indian Child Welfare Acts do not apply to this proceeding: . Based upon the following, the petitioner knows or has reason to know the child is an Indian child as defined in RCW 13.38.040 and 25 U.S.C. 247 1903(4) and the Federal and Washington State Indian Child Welfare Acts do apply to this proceeding: . The petitioner has made the following preliminary efforts to provide notice of this proceeding to all tribes to which the petitioner knows or has reason to know the child is or may be (1) a member or (2) eligible for membership if the biological parent is also a member: . 1.6 Parents Unable to Assume Custody of the Child: The Department of Children, Youth, and Families made reasonable efforts and was unable to ascertain the identity, location and custodial status of any parent who is not a party to the placement agreement. The parents listed in paragraph 1.2, whose custodial status is , cannot assume custody of the child because: American LegalNet, Inc. www.FormsWorkFlow.com PT For Rev of Out-of-Home Placement (PTDDP) - Page 3 of 3 WPF JU 12.0100 (07/2018) - JuCR 3.3; RCW 13.34.270(1),(2); RCW 74.13.350 . II. Relief Requested I request that the court review the child222s placement, make a determination that continued Out-of-Home Placement is in the best interest of the child, and take other necessary action as provided in RCW 13.34.270. Dated: Petitioner Type or Print Name/Title WSBA No. III. Certification I certify under penalty of perjury under the laws of the state of Washington that the representations in the foregoing Petition for Review of Out-Of-Home Placement are true and correct. Signed at (city), Washington on (date). Signature I have examined the petition and have determined that it is reasonably justifiable. Probation Officer: Signature Type or Print Name American LegalNet, Inc. www.FormsWorkFlow.com