Fla. R. Juv. P. Form 8.960

AFFIDAVIT AND PETITION FOR PLACEMENT IN SHELTER

COMES NOW, the undersigned, who being first duly sworn

says:

1. On.....(date)..... at.......... a.m./p.m. the above named

minor child(ren) was/were found within the jurisdiction of this

court.

..... The child(ren) was/were taken into custody by...........

..... The child(ren) need(s) to be taken into protective custody.

2. The name, age, special needs, and residence of this/these

child(ren) is/are:

Birth Special

Name date Sex Needs Address

3. The name, relationship to the child(ren), and address of

the child(ren)’s parents or other legal custodian(s) is/are:

Name Relationship Address

4. The following individuals who were listed in #3 above

have been notified in the following manner of the date, time, and

location of this hearing:

Name Manner Notified

…………………………………

………………………………….

…………………………………

………………………………….

…………………………………

………………………………….

5. There is probable cause that the child(ren)

..... a. has/have been abused, abandoned, or neglected ort

is/are in imminent danger of illness or injury as a result of abuse,

abandonment, or neglect;

..... b. was/were with a parent or legal custodian who has

materially violated a condition of placement imposed by the court;

..... c. has/have no legal custodian, or responsible adult relative

immediately known and available to provide supervision and care;

because...........

6. The provision of appropriate and available services will

not eliminate the need for placement of the child(ren) in shelter care

because:

..... a. an emergency existed in which the child(ren) could not

safely remain in the home;

..... b. the home situation presents a substantial and immediate

danger to the child(ren) which cannot be mitigated by the provision

of preventive services;

..... c. the child(ren) could not be protected in the home despite

the provision of the following services and efforts made by the

Department of Children and Families to prevent or eliminate the

need for placement in shelter care;

..... d. the child(ren) cannot safely remain at home because

there are no preventive services that can ensure the safety of the

children.

7. The department has made reasonable efforts to keep the

siblings together after the removal from the home. The reasonable

efforts of the department were..........

..... a. The children are currently placed together...........

..... b. A foster home is not available to place the siblings

together because...........

..... c. It is not in the best interest of each child that all the

siblings be placed together in out-of-home care because...........

8. On-going visitation or interaction between the siblings

.....(list)..... is

..... a. recommended as follows...........

..... b. not recommended because visitation or interaction would

be contrary to the safety or well-being of.....(name(s))..... because

9. The child(ren) is/are in need of and the petitioner

requests the appointment of a guardian ad litem.

10. The petitioner requests that the parents, if able, be

ordered to pay fees for the care, support, and maintenance of the

child(ren) as established by the department under chapter 39,

Florida Statutes.

11. The petitioner requests that the parents be ordered to

provide to the Department of Children and Families and the

Department of Revenue financial information necessary to

accurately calculate child support under section 61.30, Florida

Statutes, within 28 days of this order.

12. This affidavit and petition is filed in good faith and under

oath.

WHEREFORE, the affiant requests that this court order that

this/these child(ren) be placed in the custody of the department

until further order of this court and that the place of such custody

shall be:

..... at the discretion of the Department of Children and Families;

..... at the home of a responsible adult relative, .....(name).....,

whose address is...............;

..... other.

Moving Party

.....(attorney’s name).....

.....(address and telephone

number).....

E-mail address: ..........

Florida Bar number: ..........

Verification

NOTICE TO PARENTS/GUARDIANS/LEGAL CUSTODIANS

A date and time for an arraignment hearing is normally set at

this shelter hearing. If one is not set or if there are questions, you

should contact the Juvenile Court Clerk’s Office at........... A copy of

the Petition for Dependency will be given to you or to your attorney,

if you have one. A copy will also be available in the clerk’s office.

You have a right to have an attorney represent you at this hearing

and during the dependency proceedings and an attorney will be

appointed for you if you request an attorney and the court finds

that you are unable to afford an attorney.

COMMENT: The following paragraph must be in bold, 14 pt.

Times New Roman or Courier font.

If you are a person with a disability who needs any accommodation to

participate in this proceeding, you are entitled, at no cost to you, to the

provision of certain assistance. Please contact.....(name, address, telephone

number)..... at least 7 days before your scheduled court appearance, or

immediately upon receiving this notification if the time before the scheduled

appearance is less than 7 days. If you are hearing or voice impaired, call 711.