Or Taking Child into Custody/Place in Shelter Care (ORTCC) - Page 1 of 3 WPF JU 02.0110 (07/2018) - JuCR 2.1, 2.2; RCW 13.34.030, .050, .060 Superior Court of Washington County of Juvenile Court Dependency of: D.O.B.: No: Order to Take Child Into Custody and Place in Shelter Care (ORTCC) I. Basis The court has considered a motion, statement and declaration requesting an order to take the above-named child into custody. II. Findings 2.1 A petition has been filed with the court alleging that the child is dependent pursuant to RCW 13.34.030. 2.2 It is currently contrary to the child222s welfare for the child to remain at home. The petition and/or supporting declarations and affidavits establish reasonable grounds to believe that the child is dependent and that, if the child is not taken into custody, the child222s health, safety, and welfare will be seriously endangered. 2.3 The petitioner has demonstrated that there is a risk of imminent harm to the child in the child222s home. The assessment of risk by petitioner constitutes reasonable efforts to prevent or eliminate the need for removal of the child from the child222s home and: because of the risk of imminent harm to the child, there are no reasonably available services that can be provided to the parent(s) to maintain the child in the child222s home at this time; services previously offered or provided to the parent(s) have not remedied the unsafe conditions in the home; petitioner is currently unaware of any parent, guardian, or legal custodian known who is available to take custody of the child; and/or Other American LegalNet, Inc. www.FormsWorkFlow.com Or Taking Child into Custody/Place in Shelter Care (ORTCC) - Page 2 of 3 WPF JU 02.0110 (07/2018) - JuCR 2.1, 2.2; RCW 13.34.030, .050, .060 III. Order 3.1 A law enforcement officer, probation counselor, or child protective services worker shall take the above named minor child into custody and place the child in a facility licensed pursuant to RCW 74.15.030, or in a home not required to be licensed pursuant to that section, under the supervision of The Department of Children, Youth, and Families (DCYF). 3.2 DCYF may authorize evaluations of the child222s physical or emotional condition, routine medical and dental examination and care, and all necessary emergency care. 3.3 The child shall remain in shelter care for not more than 72 hours from the time the child is taken into custody, excluding Saturdays, Sundays, and holidays, unless the court enters an order authorizing continued shelter. Dated: Judge/Commissioner Presented by: Signature Type or Print Name/Title Copy received; Approved for Entry; Notice of Presentation Waived: Mother Mother222s Lawyer WSBA No. Pro se; advised of right to counsel Father Father222s Lawyer WSBA No. Pro se; advised of right to counsel Child222s Guardian Guardian Ad Litem222s Lawyer WSBA No. None appointed DCYF Representative DCYF222s Lawyer WSBA No. Other (If the mother, father, guardian, or other person signs without legal representation, the certification below shall also be signed.) American LegalNet, Inc. www.FormsWorkFlow.com Or Taking Child into Custody/Place in Shelter Care (ORTCC) - Page 3 of 3 WPF JU 02.0110 (07/2018) - JuCR 2.1, 2.2; RCW 13.34.030, .050, .060 CERTIFICATION I certify under penalty of perjury under the laws of the state of Washington that I have read or been told the contents of the Order to Take Child Into Custody And Place in Shelter Care and I agree that the order is accurate and should be signed by the court. Mother Date and Place of Signature Father Date and Place of Signature Child222s Guardian Date and Place of Signature Other Date and Place of Signature American LegalNet, Inc. www.FormsWorkFlow.com