FOR DEPARTMENT OR COURT USE ONLY Application submitted by: (Name and Address) Name: Street Address City, State: Telephone Number: SUPERIOR COURT OF CALIFORNIA, COUNTY OF SACRAMENTO Street Address: 9605 Kiefer Blvd. 3341 Power Inn Road City and Zip Code: Sacramento, CA 95827 Sacramento, CA 95826 Branch Name: SITTING AS THE JUVENILE COURT NAME OF CHILD/MINOR: Date of Birth: DECLARATION: INSPECTION AND LIMITED RELEASE OF JUVENILE RECORDS WITHOUT FURTHER COURT ORDER – JUVENILE COURT CASE FILED (Welfare & Institutions Code § 827, California Rules of Court, rule 5.552, CASE NUMBER: Standing Order SSC-JV-99-021, Attachment A, section I.) I, ________________________________________________________________, do hereby declare that: 1. A case concerning the above-named Child/Minor has been filed in the Juvenile Court □ □ Dependency Division Delinquency Division 2. I am a person described in Welfare and Institutions Code section 827(a)(1)(G) or (J)-(O) or 829, to wit: □ □ □ □ 1. A superintendent or designee of the school district where the child/minor is enrolled or attending school. [WIC § 827(a)(1)(G)] 2. A person, agency or multidisciplinary team providing treatment or supervision of the child/minor. [WIC § 827(a)(1)(K)] 3. A child custody evaluator appointed by the family law court who is actively participating in a family law case. [WIC § 827(a)(1)(L)] □ □ 4. A designee of the Sacramento division of the Department of Child Support Services. [WIC § 827(a)(1)(N)] 5. A juvenile justice commissioner appointed pursuant to Welfare and Institutions Code § 225. [WIC § 827(a)(1)(O)] 6. A staff member for the Board of Prison Terms. [WIC § 829)] 3. Pursuant to Standing Order SSC-JV-99-021, I am requesting to view and/or copy juvenile records concerning the above-named Child/Minor currently in the possession of the: □ □ Juvenile Court Dept. of Health & Human Services □ □ Probation Department Court-Appointed Special Advocates 4. Inspection - Pursuant to Standing Order SSC-JV-99-021, section B.4.b., I am allowed to view the following records: a. The petition and all other documents filed in a Juvenile Court delinquency or dependency case; b. Reports to the Juvenile Court in a delinquency or dependency case prepared by probation officers or social workers of the Child Protective Services Division of the Department of Health and Human Services , and Court-Appointed Special Advocates; JC\E-015 Eff. 7/22/08 Declaration: Inspection and Limited Release of Juvenile Records Without Further Court Order Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com c. Documents not filed with the Juvenile Court, but made available to, or created by, probation officers, social workers of the Child Protective Services Division of the Department of Health and Human Services, or Court-Appointed Special Advocates (CASA) in preparation of reports as part of an investigation to determine whether a child/minor comes within the jurisdiction of the Juvenile Court or for filing a report with the Juvenile Court for a delinquency or dependency case; d. Transcripts that have previously been prepared, records, or reports relating to matters prepared or released by the Juvenile Court, Probation Department, or the Child Protective Services Division of the Department of Health and Human Services, for a Juvenile Court delinquency or dependency case; e. Documents admitted into evidence at Juvenile Court hearings for a delinquency or dependency case. 5. Copying: Pursuant to Standing Order SSC-JV-99-021, section D, I am allowed to copy only the following documents: a. b. c. d. Original, subsequent and supplemental petitions filed with the Court; Petitions/motions to modify prior court orders; Minute orders signed by the Court clerk; and Orders signed by judicial officers. To obtain copies of any other juvenile records I must file a JV-570 Petition for Disclosure of Juvenile Court Records which specifically identifies the documents by title and date and obtain a further court order. 6. I certify that I am requesting these records for use in my capacity described above and that I will not disseminate any portion of the records released to me or information relating to their contents, other than to other persons or agencies described in Standing Order SSC-JV-99-021 and that no portion of those records and no information relating to the contents of those records shall be made attachments to any other documents without the prior approval of the Presiding Judge of the Juvenile Court, unless they are used in connection with and in the course of a criminal investigation or a proceeding brought to declare a person a dependent child or ward of the juvenile court. I declare under penalty of perjury that the above is true and correct. Executed this _________ day of __________________________________ in Sacramento, California. Signature: __________________________________________________ Name (printed): _____________________________________________ Title (printed): ______________________________________________ Address and telephone: _______________________________________ __________________________________________________________ JC\E-015 Eff. 7/22/08 Declaration: Inspection and Limited Release of Juvenile Records Without Further Court Order Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com For Office Use Only Date: _________________ □ Granted □ Denied Clerk Processing: _________________________________ JC\E-015 Eff. 7/22/08 Declaration: Inspection and Limited Release of Juvenile Records Without Further Court Order Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com