Ill. R. Cir. Ct. Cook Cnty. 19A.3
STATE OF ILLINOIS COUNTY OF COOK | ) |
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IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, JUVENILE DIVISION | |
IN THE INTEREST OF | ) |
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) | No. |
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______________________ A Minor | ) |
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AFFIDAVIT DOCUMENTING DCFS EFFORTS
I, __________________________________________, certify and state as follows:
1. I am a(n) investigator / DCFS caseworker (circle one) assigned to the above captioned case.
2. The event(s) that brought this case to the attention of DCFS at this time is:
____________________________________
3. The specific reason(s) I have identified that lead(s) DCFS to place or consider placing the child are as follows:
____________________________________
The above information is based on:
_____My own personal knowledge.
_____Information received from other sources, which I believe to be true.
4. Based on the reason(s) I have identified, (check one):
_____(a) The specific efforts (with names of providers, if applicable) that were made to prevent placement are explained and described below:
_______________________________
_______________________________
or
_____(b) Under the circumstances, no efforts would prevent placement of the child because of the following:
____________________________________
____________________________________
The above information is based on:
_____My own personal knowledge.
_____Information received from others, which I believe to be true.
Under penalties provided by law, pursuant to Section 1-109 of the Illinois Code of Civil Procedure, I certify that the statements set forth above are true and correct, except as to matters stated above on information and belief as to these matters. I certify that I believe those statements to be true.
__________________________________________
(Signature)
__________________________________________
(Date)
Ill. R. Cir. Ct. Cook Cnty. 19A.3