COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : : : Defendant(s) : ...................................................... IN THE SUPERIOR COURT OF WASHINGTON, COUNTY OF KING THE PEOPLE OF THE STATE OF NEW YORK In the Cause N° TO MOTION, DECLARATION, AUTHORIZATION AND ORDER TO RELEASE CPS RECORDS (ORAU) GREETINGS: (CLERK’S ACTION REQUIRED) WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the I. MOTION & DECLARATION The undersigned does hereby declare under penalty of perjury contempt ofto the and will make you liable to Your failure to comply with this subpoena is punishable as a according court laws of the State of Washington that the following is true for correct: the party on whose behalf this subpoena was issuedand a maximum penalty of $50 and all damages sustained as a result of your failure to comply. I have filed an action for nonparental custody and am requesting that the court direct DCFS/CPS to release information as to any “founded” CPS reports as, well of the Justices of the Witness, Honorable one as information regarding any pending CPS investigations in which 20or any adult members of my household are I Court in County, day of , named as a subject. This request is based on RCW 26.10 and the attached authorizations to release this information. Each adult member of my household, as well as myself, has signed and completed the authorizations to release this information on the following pages. I (Attorney must understand that any such information may be shared with the court sign aboveparties name below) and all and type to the court action. Attorney(s) for City and State: ______________________ Date: ______________________ ______________________________________ Signature of Petitioner Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: MOTION/AUTHORIZATION/ORDER FOR RELEASE OF CPS RECORDS (ORAU) KCSCC 1/2004 - L:/FORMS/COPYCTR/DR FORMS/26.10/ 1 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : II. AUTHORIZATION TO RELEASE INFORMATION TO THE COURT JUDICIAL SUBPOENA Plaintiff(s) : I authorize Department -against- and Health Services of the State of Washington (DCFS/CPS) of Social to release information regarding any “founded” or pending CPS reports in which I am named as : a subject to King County Superior Court. This information may be provided verbally or by computer data transfer, mail, fax or hand delivery. I understand that this authorization allows : the court to review the information and that the records may be made available to the parties in this case and as a result may be made publicly accessible. This permission is valid until this case Defendant(s) : . .is .dismissed .or. completed. . I .understand. that. my. . . . . . . . . . no longer be protected under the . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . records may laws that apply to DSHS after this disclosure. A copy of this order is valid to give my permission to disclose records. Petitioner: THE PEOPLE OF THE STATE OF NEW YORK Authorized by (signature): Date Other names used: ______________________________ signed_____________ TO Printed Name ______________________________ Date of Birth:________ I am a male_ female__ __________________________ __________________________ Counties of Residence since 1998:_____________________ __________________________ GREETINGS: Other Petitioners/Adult household members in Petitioner’s household: WE COMMAND aside, you and each Authorized by (signature): YOU, that all business and excuses being laidOther names used: of you attend before Date , the Honorable at the ______________________________ signed_____________ Court __________________________ __________________________ located at County of Date of20 Counties of inPrinted Name , on the room day of , Birth:________ o'clock in the Residenceand at any recessed , at noon, since ______________________________ I as a a male_ in this action on the part of the am witness female__ 1998:_____________________ or adjourned date, to testify and give evidence __________________________ Authorized by (signature): Date Other names used: ______________________________ signed_____________ __________________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to __________________________ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Printed Name Date of Birth:________ Counties of Residence since result of your failure to comply. ______________________________ I am a male_ female__ 1998:_____________________ __________________________ Witness, Honorable , one of the Justices of the [Attach releases for any additional adults in petitioner’s household] Court in County, day of , 20 III. ORDER (Attorney must sign the and type name below) It is hereby ordered that DCFS/CPS shall provide information regarding aboveperson(s) signing the above release(s) to King County Superior Court Clerk’s Office, 516 Third Avenue, Seattle, WA 98104 within two weeks from receipt of this order. The Superior Court Clerk’s Office will mail a copy of this order to DCFS/CPS. It is further ordered that any such records shall be filed Attorney(s) for under seal and will not be made available to anyone other than the court, the parties and their attorneys without a court order. DATED:_________________ ___________________________________ Office and P.O. Address JUDGE/COURT COMMISSIONER PRESENTED BY: ______________________ Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: MOTION/AUTHORIZATION/ORDER FOR RELEASE OF CPS RECORDS (ORAU) KCSCC 1/2004 - L:/FORMS/COPYCTR/DR FORMS/26.10/ 2 American LegalNet, Inc. www.USCourtForms.com