FOR DEPARTMENT 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 OF JUVENILE RECORDS WITHOUT FURTHER COURT ORDER (NO COPIES) – JUVENILE COURT CASE NOT FILED (Welfare & Institutions Code § 827, California Rules of Court, rule 5.552, Standing Order SSC-JV-99-021, Attachment A, section I.) I, ________________________________________________________________, do hereby declare that: 1. No case concerning the above-named Child/Minor has been filed in the Juvenile Court. 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, section B.4.a., I am requesting to view juvenile records concerning the above-named Child/Minor currently in the possession of the: □ Probation Department □ Dept. of Health & Human Services 4. Inspection - Pursuant to Standing Order SSC-JV-99-021, section C.1., I am allowed to view, but not copy, documents in the possession of the Probation Department or Department of Health and Human Services, developed or retained as part of an investigation to determine whether a person comes within the jurisdiction of the Juvenile Court, concerning which no jurisdictional petition was filed in the Juvenile Court pursuant to Welfare and Institutions Code sections 300, 601 or 602. 5. Copying: To obtain copies of the documents listed in section four (4), 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. JC\E-016 Eff. 7/22/08 Declaration: Inspection of Juvenile Records Without Further Court Order, No Copying Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com 6. I certify I am requesting these records for use in my capacity described above and I will not disseminate any portion of the information relating to their contents, other than to other persons or agencies described in Standing Order SSC-JV-99-021 and that 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: _______________________________________ __________________________________________________________ For Office Use Only Date: _________________ □ Granted □ Denied Clerk Processing: _________________________________ JC\E-016 Eff. 7/22/08 Declaration: Inspection of Juvenile Records Without Further Court Order, No Copying Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com