IN THE __________DISTRICT JUVENILE COURT, _______________________ COUNTY, STATE OF UTAH ___________________________________ Petitioner's Name ___________________________________ Street Address ___________________________________ City, State, ZIP Date of Birth vs. Division of Child and Family Services, Respondent 195 North 1950 West Salt Lake City, Utah 84116 (801) 538-4100 VERIFIED PETITION AGAINST SUBSTANTIATION IN DCFS LICENSING DATABASE (FORM A) Case No. ______________ Judge _________________ Petitioner swears that the following is true: (1) Petitioner received notice on or about _____________ that the Division of Child and Family Services had made a supported finding of severe abuse or neglect against the Petitioner, and that Petitioner would be included in the Division of Child and Family Services licensing database. (Attach copy of notice from agency). (2) Petitioner has NOT been subject to any of the following court determinations with respect to the alleged incident of abuse or neglect: conviction; juvenile court adjudication; plea of guilty; plea of guilty and mentally ill; or no contest. (3) Petitioner challenges the finding made by Division of Child and Family Services, and inclusion in the Licensing Database. Petitioner requests a court hearing because: [Describe in detail facts which you believe contradict the finding of the Division of Child and Family Services, including what happened, where, who was involved (including minor children and family and household members), and if medical or police intervention was required. Attach relevant medical, dental, or police records.] ______________________________________________________________________________ ______________________________________________________________________________ Rev. April 2011 1 American LegalNet, Inc. www.FormsWorkFlow.com ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (4) For these reasons, Petitioner respectfully requests that the Court enter an order establishing that the finding of the Division of Child and Family Services was unsubstantiated, or without merit, and to order that Division of Child and Family Services remove Petitioner's name from the Licensing Database. Petitioner: __________________________________ SUBSCRIBED and SWORN to before me on _________________, 20 ___. ______________________________ Clerk, Deputy or Notary THIS PETITION MUST BE SERVED PLEASE FOLLOW THE INSTRUCTIONS THAT ACCOMPANY THIS FORM Rev. April 2011 2 American LegalNet, Inc. www.FormsWorkFlow.com NOTICE OF HEARING THE STATE OF UTAH, JUVENILE COURT TO THE DIVISION OF CHILD AND FAMILY SERVICES: You are directed to appear at a hearing and answer the above claim: On Date: __________________ At Time: ______________ at Address:______________________________________________________________________ Dated _____________, 20 _____ ______________________________ Clerk or Deputy In compliance with the Americans with Disabilities Act, individuals needing special accommodations (including auxiliary communicative aids and services) during this proceeding should call the court clerk at (phone)_________, at least three working days prior to the proceeding. Rev. April 2011 3 American LegalNet, Inc. www.FormsWorkFlow.com SUBSTANTIATION PROCEEDINGS: INSTRUCTIONS TO THE PETITIONER Substantiation proceedings are governed by Utah Code 63-46b-15(2), and 78A-6-323. If you have any questions not addressed in these instructions, refer to the Utah Code. You should be able to locate a copy in your local library, on the State Court Website at http://www.utcourts.gov (for procedural rules), or the Legislature's Website at http://www.state.le.us (for the Utah Code). HOW TO FILE FOR A HEARING 1. FILING SUIT. You are the `PETITIONER' in this case and the `RESPONDENT' is the Division of Child and Family Services. If the judge determines that the finding of the Division of Child and Family Services is "unsubstantiated" or "without merit" as defined in Utah Code 62a4a-101, the judge will order that your name be removed from the Licensing Information System. In this action, no claims can be made for money. The Juvenile Court has exclusive jurisdiction over substantiation proceedings to make a finding of "substantiated", "unsubstantiated", or "without merit". If the court finds that Division of Child and Family Services claim is unsubstantiated, or without merit, the Court will order Division of Child and Family Services to remove your name from the Licensing Database. 2. COURT HEARING. You must prepare the Petition, sign it in the presence of a notary public or court clerk, have your signature notarized, file it with the court clerk, and pay the $155.00 filing fee. The Petition should be typewritten, but will be accepted if legibly handwritten. The clerk will set two hearing dates (pre-trial, and adjudicatory hearing) and give you a copy of the Petition with the hearing dates on it. The first hearing will be a pre-trial hearing, and is intended for parties to inform the court of the legal and factual issues to be presented at the adjudicatory hearing. Any stipulations or agreements between the parties should be presented at the pre-trial hearing. The second hearing, the adjud