Fill and Sign the Wa Cps Information

Superior Court of Washington, County of In re custody of: Children : Petitioner/s (person/s who started this case) : Respondents ( parents and any guardian or custodian) : No. Order to DSHS to Release CPS Information (Non-Parent Custody) (ORDINFO)  Clerk’s action required: 5 Order to DSHS to Release CPS Information (Non-Parent Custody) 1. Petitioner/s filed a Non-Parent Custody Petition . The Court needs information from the Department of Social and Health Services, Child Protective Services. 2. The Court orders the Department to provide information as allowed by RCW 13.50.100 about investigations in which:  the children involved in this case were alleged victims of abandonment, abuse or neglect; or  the Petitioner/s, or any person age 16 or older who lives with Petitioner/s, is the subject of a founded or currently pending CPS investigation started after October 1, 1998. The Department must provide this information under a Sealed CPS Information cover sheet (form FL Non-Parent 408) to the court at this address: Superior Court Clerk, County address city state zip The Department must provide the information by (date): or within a reasonable amount of time if no date is specified. RCW 26.10.135, 13.50.100 Mandatory Form (05/2016) FL Non-Parent 407 Order to DSHS to Release CPS Information (Non-Parent Custody) p. 1 of 3 3. List the children: Child’s name Age Child’s name Age 1. 4. 2. 5. 3. 6. 4. List Petitioner/s and anyone 16 or older living in the Petitioner’s home: Petitioner Other Petitioner, if any Name (first, middle, last): Any other name used: Birth date (mm / dd / yyyy): Other person in the home #1 Other person in the home #2 Name (first, middle, last): Any other name used: Birth date (mm / dd / yyyy): (For 16 or 17-year-olds, list age instead of birth date.) Other person in the home #3 Other person in the home #4 Name (first, middle, last): Any other name used: Birth date (mm / dd / yyyy): (For 16 or 17-year-olds, list age instead of birth date.) 5. Clerk’s Action: The clerk shall forward a copy of this order to DSHS. Information received from DSHS in response to this order shall be filed under seal. Only the parties in this case, their lawyers, the Guardian ad Litem (if any) and the person whose information was released may have access to this information. Other: RCW 26.10.135, 13.50.100 Mandatory Form (05/2016) FL Non-Parent 407 Order to DSHS to Release CPS Information (Non-Parent Custody) p. 2 of 3 6. The information DSHS provides in response to this order is confidential. Anyone who sees the information must keep it confidential and protect against unauthorized disclosure. Ordered. Date Judge or Commissioner Petitioner and Respondent/s or their lawyers fill out below. This document (check any that apply) : This document (check any that apply) : is an agreement of the parties is an agreement of the parties is presented by me is presented by me may be signed by the court without notice to me may be signed by the court without notice to me Petitioner signs here or lawyer signs here + WSBA # Respondent signs here or lawyer signs here + WSBA # Print Name Date Print Name Date This document (check any that apply) : This document (check any that apply) : is an agreement of the parties is an agreement of the parties is presented by me is presented by me may be signed by the court without notice to me may be signed by the court without notice to me Other Petitioner or lawyer signs here + WSBA # Other Respondent or lawyer signs here + WSBA # Print Name Date Print Name Date RCW 26.10.135, 13.50.100 Mandatory Form (05/2016) FL Non-Parent 407 Order to DSHS to Release CPS Information (Non-Parent Custody) p. 3 of 3