19A.3 Affidavit of Efforts
(A) Any motion for a temporary custody hearing filed by the Department of Children and Family Services in the case of an alleged abused, neglected or dependent minor, must be accompanied by an affidavit signed by a representative of the Department of Children and Family Services setting forth the efforts taken by the Department of Children and Family Services to prevent or eliminate the necessity of removal of the minor from his or her home. This affidavit shall be attached to the motion.
(B) The affidavit shall be substantially in the following form:
| STATE OF ILLINOIS
COUNTY OF COOK
|
)
)
) |
|
IN THE CIRCUIT COURT OF
COOK COUNTY, ILLINOIS
COUNTY DEPARTMENT, JUVENILE DIVISION |
| IN THE INTEREST OF
___________________
A Minor
|
)
)
)
)
)
) |
No. |
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)
[Adopted December 31, 1992, effective January 4, 1993.]
