Form A dopted for Mandatory Use L - 0 733 ( New April 11, 2019 ) ELDERCARING COORDINATOR REPORT OF AN EMERGENCY www.occourts.org ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NO.: NAME: FIRM NAME: STREET ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE NO.: FAX NO.: E - MAIL ADDRESS: ATTORNEY FOR (name): FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE CENTRAL JUSTICE CENTER 700 Civic Center Dr ive West Santa Ana, CA 92701 - 4045 IN THE MATTER OF: ELDERCARING COORDINATOR REPORT OF AN EMERGENCY CASE NUMBER: The undersigned Eldercaring Coordinator reports an emergency to the court: 1. With notice to the parties. A party has obtained a final order or injunction of protection against domestic violence or has been arrested for an act of domestic violence, elder abuse, neglect or exploitation. 2. Without notice to the parties. (check all that apply) a. There is a reasonable cause to suspect the elder has been or is being abused, neglected, or - being are in immediate jeopardy ; or b. There is a reasonable cause to suspect that a child will suffer or is suffering abuse, neglect, or abandonment; or c. wrongfully remove or is wrongfully removing the elder from the jurisdiction of the court without prior approval of the court ; or d. It is necessary to protect any person from future acts that would constitute domestic violence or abuse, neglect, or exploitation of an elderly or disabled adult. 3 . There is a pending investigation by the Adult or Child Protective Services. 4. Describe the emergency: I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. DATE PRINTED NAME SIGNATURE OF ELDERCARING COORDINATOR American LegalNet, Inc. www.FormsWorkFlow.com