Petition And Affidavit Seeking Ex Parte Order Requiring Involuntary Examination Form - Hernando County, Florida Page 4
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4Petition and Affidavit Seeking Ex Parte Order Requiring Involuntary Examination
(Page 4)
Provide the following identifying information about the person (if known) if it is determined necessary to take the
person into custody for examination:
DOB:
_____________________________________________________
_______________________
County of Residence:
Age:
Sex :
Male
Female
Race:
________________
Attach a picture of the PERSON if possible.
Picture attached:
No
Yes
Height:
________________
Weight:
________________
Hair Color:
________________
Eye Color:
________________
Does the PERSON have access to any weapons?
No
Yes
If yes, describe:
________________________________________________
Is the PERSON violent now?
No
Yes
Has the person been violent in the recent past?
No
Yes
If Yes, Describe:
______________________________________________________________________________________
Does the PERSON have any pending criminal charges against him/her?
No
Yes
If yes, describe:
______________________________________________________________________________________
GUARDIANSHIP:
1) Does the PERSON have a legal guardian?
No
Yes
2) Is there a pending petition to determine the PERSON’s capacity and for the appointment of a guardian?
No
Yes
If YES to either of the above, provide the name, address and phone number of the current or proposed guardian.
______________________________________________
________________
Name:
Phone:
(_________)
______________________________________________
___________________
__________
Address:
City:
Zip:
_________________________________________________________________________________________________________________________
______________________________________
PHYSICIAN:
Name:
Phone:
(_________)
_________________________________________________________
MEDICATIONS: Provide name of medications if known.
CASE MANAGEMENT: Provide name and phone number of case manager or case management agency, if known.
______________________________________________
________________
Name:
Phone:
(_________)
I understand that this sworn statement is given under oath and will be treated as though it was made before a judge in a
court of law. I understand that any information in this sworn statement which is not to the best of my knowledge and
done in good faith may expose me to a penalty for perjury and other possible penalties under the statutes of the State of
Florida.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it are true.
: ________________________________________________
Signature of Affiant/Petitioner
OR
SWORN TO AND SUBSCRIBED before me
SWORN TO AND SUBSCRIBED before me
this __________ day of ________________________, ______________
this __________ day of ________________________, ______________
Day
Month
Year
Day
Month
Year
by _____________________________________ who is personally known
DON BARBEE, JR
Clerk of Circuit Court
Hernando County, Florida
to me or presented ________________________________ as identification.
___________________________________________________________
By: _______________________________________________________
Notary Public - State of Florida
Deputy Clerk
My Commission expires: Date_____________________
A copy of the petition(s) must be attached to an Ex Parte Order for Involuntary Examination and accompany the
person to the nearest receiving facility.
See s. 394.463, Florida Statutes
CF-MH 3002, Oct 11(obsoletes previous editions) (Recommended Form)
BAKER ACT
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