SUPERIOR COURT OF WASHINGTON COUNTY OF _______________________ JUVENILE COURT Dependency of: No: Motion for Order to Take Child Into Custody D.O.B.: (MT) I. Motion The undersigned moves the court for an order to take the above-named child into custody based upon the statement that follows. II. Statement The undersigned states that: 2.1 A petition has been filed with the Juvenile Court alleging that the child is dependent and that if the child is not taken into custody, the child's health, safety, and welfare will be seriously endangered. There are reasonable grounds to believe that the child is dependent and the child's health, safety, and welfare will be seriously endangered if the child is not taken into custody. The facts in support of paragraph 2.2 above and that demonstrate a risk of imminent harm to the child, are attached and are hereby incorporated by reference or are as follows: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Mt for Or to Take Child Into Custody (MT) - 1 of 2 WPF JU 02.0100 (11/2009) - JuCR 2.1; RCW 13.34.050, .070(6) American LegalNet, Inc. www.FormsWorkFlow.com 2.2 2.3 _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ . (Continue on separate declaration if necessary.) III. Declaration I declare under penalty of perjury under the laws of the state of Washington that the foregoing statement is true and correct. Signed at ______________________________ [City], Washington on ______________________ [Date]. ______________________________________ Signature ______________________________________ Print Name ______________________________________ Address ______________________________________ Mt for Or to Take Child Into Custody (MT) - 2 of 2 WPF JU 02.0100 (11/2009) - JuCR 2.1; RCW 13.34.050, .070(6) American LegalNet, Inc. www.FormsWorkFlow.com