Motion Declaration Authorization And Order To Release CPS Records

IN THE SUPERIOR COURT OF WASHINGTON, COUNTY OF KING In the Cause N MOTION, DECLARATION, AUTHORIZATION AND ORDER TO RELEASE CPS RECORDS (ORAU) (CLERKS ACTION REQUIRED) I. MOTION & DECLARATION The undersigned does hereby declare under penalty of perjury according to the laws of the State of Washington that the following is true and correct: I have filed an action for nonparental custody and am requesting that the court direct DCFS/CPS to release information as to any f ounded CPS reports as well as information regarding any pending CPS investigations in which I or any adult members of my household are named as a subject. This request is based on RCW 26.10 and the attached authorizations to release this information. Each adult member of my household, as well as myself, has signed and completed the authorizations to release this information on the following pages. I understand that any such information may be shar ed with the court and all parties to the court action. City and State: ______________________ Date: ______________________ ______________________________________ Signature of Petitioner MOTION/AUTHORIZATION/ORDER FOR RELEASE OF CPS RECORDS (ORAU) 1KCSCC 1/2004 - L:/FORMS/COPYCTR/DR FORMS/26.10/ <<<<<<<<<********>>>>>>>>>>>>> 2 II. AUTHORIZATION TO RELEASE INFORMATION TO THE COURT I authorize Department of Social and Health Services of the State of Washington (DCFS/CPS) to release information regarding any founded or pending CPS reports in which I am named as a subject to King County Superior Court. This information may be provided verbally or by computer data transfer, mail, fax or hand delivery. I understand that this authorization allows the court to review the information and that the records may be made available to the parties in this case and as a result may be made publicly ac cessible. This permission is valid until this case is dismissed or completed. I understand that my records may no longer be protected under the laws that apply to DSHS after this disclosure. A copy of this order is valid to give my permission to disclose records. Petitioner: Authorized by (signature): Date Other names used: ______________________________ signed_____________ __________________________ __________________________ Printed Name Date of Birth:________ Counties of Residence since ______________________________ I am a male_ female__ 1998:_____________________ __________________________ Other Petitioners/Adult household me mbers in Petitioners household: Authorized by (signature): Date Other names used: ______________________________ signed_____________ __________________________ __________________________ Printed Name Date of Birth:________ Counties of Residence since ______________________________ I am a male_ female__ 1998:_____________________ __________________________ Authorized by (signature): Date Other names used: ______________________________ signed_____________ __________________________ __________________________ Printed Name Date of Birth:________ Counties of Residence since ______________________________ I am a male_ female__ 1998:_____________________ __________________________ any additional [Attach releases for any additional III. ORDER It is hereby ordered that DCFS/CPS shall provide information regarding the person(s) signing the above release(s) to King County Superior Court Clerks Office, 516 Third Avenue, Seattle, WA 98104 within two weeks from receipt of this order. The Superior Court Clerks Office will mail a copy of this order to DCFS/CPS. It is fu rther ordered that any such records shall be filed under seal and will not be made available to anyone other than the court, the parties and their attorneys without a court order. DATED:_________________ ___________________________________ J UDGE/COURT COMMISSIONER PRESENTED BY: ______________________ MOTION/AUTHORIZATION/ORDER FOR RELEASE OF CPS RECORDS (ORAU) 2KCSCC 1/2004 - L:/FORMS/COPYCTR/DR FORMS/26.10/