SUPERIOR COURT OF WASHINGTON COUNTY OF _______________________ JUVENILE COURT Dependency of: No: Declaration of Shelter Care Placement Notification (DCLR) D.O.B.: 1. My name is ______________________________________ [Name]. I am over the age of 18 years and am currently employed by ________________________________________ _______________________________________ [Employer's name]. [] On __________________________________ [Date], at _____________ a.m./p.m. I informed the child's [ ] mother [ ] father [ ] guardian or legal custodian that the child had been taken into custody, the reasons why the child had been taken into custody, and their rights under Chapter 13.34 RCW, including the right to a shelter care hearing. I gave the notice [ ] by telephone [ ] in person. The substance of the notice is as follows: 2. [] [] I gave the notice in writing. A copy of the written notice is [ ] attached [ ] has been filed with the court. Decl of Shelter Care Placement Notification (DCLR) - Page 1 of 2 WPF JU 02.0150 (11/2009) - RCW 13.34.062 American LegalNet, Inc. www.FormsWorkFlow.com 3. [] I am unable to determine the whereabouts of the child's [ ] mother [ ] father [ ] guardian or legal custodian. The following efforts have been made to investigate and determine the person's whereabouts: [] I [ ] sent [ ] delivered the shelter care placement notification to the last known address of the child's [ ] mother [ ] father [ ] guardian or legal custodian. I certify under penalty of perjury under the laws of the state of Washington that the foregoing declaration is true and correct. Signed at ____________________________ [City], Washington on ______________________ [Date]. _____________________________________________ Signature _____________________________________________ Print Name _____________________________________________ Title/Agency Decl of Shelter Care Placement Notification (DCLR) - Page 2 of 2 WPF JU 02.0150 (11/2009) - RCW 13.34.062 American LegalNet, Inc. www.FormsWorkFlow.com