Cina Request and Tpr Checklist and Affidavit

CINA REQUEST AND TPR CHECKLIST AND AFFIDAVIT

Pursuant to Iowa Code Chapter 598B, the undersigned herby submits the following information in conjunction with the Department of Human Services’ request for either a CINA petition or a petition for termination of parental rights. The undersigned swears or affirms that the following information is true and accurate to the best of his or her knowledge as of the date of the signature.

1. The Child/Children:

Has/Have lived at the listed residence for the last five years.

Has/Have not lived at the listed residence for the last five years. A list of the child’s residence in the last five years, including the names and present whereabouts (if known) of each person with whom the child has lived in the last five years, is attached as Exhibit ______.

2. This Worker:

Has not participated as a party or witness or in any capacity in any other proceeding concerning the custody of or visitation with the child.

Has participated as a party or witness or in any other capacity in any other proceeding concerning the custody of or visitation with the child, and the court, case number, and the date of any custody determinations are attached, as Exhibit ______.

3. This Worker:

Is currently unaware of any currently ongoing proceeding which could affect proceedings under this petition.

Is aware of currently ongoing proceeding which could affect proceedings under this petition and is providing the case number and description of the nature of such proceedings in an attachment marked as Exhibit ______.

4. This Worker:

Is currently unaware of any person who is not at this time a party to these proceedings who has physical custody of the child, or claims to have physical custody, or who claims to have visitation to this child.

Is aware of a person or persons who are not at this time a party to these proceedings who has physical custody of the child, or claims to have physical custody, or who claims to have visitation rights, and is attaching the name and address of each such person as Exhibit ______.



5. This Worker:

Does not believe that the health, safety, or liberty of a party or child would be unreasonably put at risk by the disclosure of information required in paragraph 1 above.

Believes that the health, safety, or liberty of a party or child would be unreasonably put at risk by the disclosure of information required in paragraph 1 above or an existing order already so provides and prays that this court order the address of the party or child or other identifying information not be disclosed in a pleading or other document filed herein.

Details are more fully explained in Exhibit ______.

Dated this ____ day of ______, 201___.

______

Iowa Department of Human Services

SUBSCRIBED AND SWORN to before me under penalty of perjury this ____ day of ______, 201__ by ______, known to me to be the person signing this affidavit.

______

Notary Public

My commission expires

CINA REQUEST - INFORMATION SHEET

CHILD’S NAME:

CHILD’S DATE OF BIRTH:

CHILD’S SOCIAL SECURITY NUMBER:

CHILD’S ADDRESS:

CHILD’S CURRENT LOCATION:

CHILD’S RESIDENCE HISTORY FOR THE PAST 5 YEARS:

NAMES/ADDRESSES WITH WHOMTHE CHILD HAS LIVED WITH FOR THE PAST 5 YEARS:

------

MOTHER’S NAME:

MOTHER’S DATE OF BIRTH:

MOTHER’S SOCIAL SECURITY NUMBER:

MOTHER’S ADDRESS:

------

FATHER’S NAME:

FATHER’S DATE OF BIRTH:

FATHER’S SOCIAL SECURITY NUMBER:

FATHER’S ADDRESS:

------

*Step-parent, legal custodian, and/or guardian ad-litem information should also be revealed.

**Multiple copies of this page will be necessary for more than one child.