On 11/3/15 at approximately 2151 hours, I, R/O S. Mendiola #354 and Ofc.

Uribe #353
responded to 53 S. Union for a report of a domestic disturbance. While en route,
communications advised that the caller stated that there was an injured female, bleeding and
lying on the floor and possibly a 2 year old infant on scene. The caller further stated that the
injured subject may have been using heroin or meth.
Upon arrival, we met up with other officers on scene speaking to Tom Ryan and Holly
Sathern. There was blood on the floor in the hallway and on the bathroom floor as well as the
bed in the bedroom. Holly had blood on her shirt, pants, on her face and matted in her hair,
although it was unclear where her injury was.
Holly was extremely uncooperative and would not answer officers questions, she only
demanded to see herself in the mirror. She was eventually transported to St. Joseph Hospital
by the EFD.
Officers attempted to speak to Tom who was highly intoxicated and talking in circles, not
making much sense. He expressed multiple times how happy he was that his son (Hank) was
not there and that his sister Becky had taken him with her. He alluded to Holly possibly using
cocaine regularly as well as earlier this evening, possibly at The Walnut.
Tom would not explain how the blood had gotten on the floor, nor would he describe what
happened to Holly. Officers did not observe any injuries on Tom or any marks on his hands.
Ofc. Uribe took photos of the scene as well as Holly's injuries later at the hospital and
uploaded them into EPD evidence.
A check of the house did not reveal any weapons or any obvious signs of an altercation.
Ofc. Uribe and I went to St. Joe's to check the status of Holly's injuries. We were informed
that Holly had received some sort of trauma to the face although it was unclear if she fell or if
it was inflicted by another person. She had swelling to the nose and a small cut at the top of
the bridge as well as a bruise to the upper right arm.
Hospital staff advised us that Holly had said that she was "was bashed in the face and then it
was lights out". They further advised that when Holly was looking in the mirror she stated,
Tommy did this." When asked who hurt her, she wouldn't reply.
When officers attempted to speak to Holly she just repeatedly asked for officers to bring her
son, or she would ask for a mirror to check out her face. She would not explain how she had
received her injuries. When asked if someone did this to her, she would just ask for her son.
Cellular Mobile
I explained

English

11/3/2015

Case Report 2015-00068305 Page 1 OF 3

 2015-00068305

On 11/3/15 at approximately 2151 hours, I, R/O S. Mendiola #354 and Ofc. Uribe #353
responded to 53 S. Union for a report of a domestic disturbance. While en route,
communications advised that the caller stated that there was an injured female, bleeding and
lying on the floor and possibly a 2 year old infant on scene. The caller further stated that the
injured subject may have been using heroin or meth.
Upon arrival, we met up with other officers on scene speaking to Tom Ryan and Holly
Sathern. There was blood on the floor in the hallway and on the bathroom floor as well as the
bed in the bedroom. Holly had blood on her shirt, pants, on her face and matted in her hair,
although it was unclear where her injury was.
Holly was extremely uncooperative and would not answer officers questions, she only
demanded to see herself in the mirror. She was eventually transported to St. Joseph Hospital
by the EFD.
Officers attempted to speak to Tom who was highly intoxicated and talking in circles, not
making much sense. He expressed multiple times how happy he was that his son (Hank) was
not there and that his sister Becky had taken him with her. He alluded to Holly possibly using
cocaine regularly as well as earlier this evening, possibly at The Walnut.
Tom would not explain how the blood had gotten on the floor, nor would he describe what
happened to Holly. Officers did not observe any injuries on Tom or any marks on his hands.
Ofc. Uribe took photos of the scene as well as Holly's injuries later at the hospital and
uploaded them into EPD evidence.
A check of the house did not reveal any weapons or any obvious signs of an altercation.
Ofc. Uribe and I went to St. Joe's to check the status of Holly's injuries. We were informed
that Holly had received some sort of trauma to the face although it was unclear if she fell or if
it was inflicted by another person. She had swelling to the nose and a small cut at the top of
the bridge as well as a bruise to the upper right arm.
Hospital staff advised us that Holly had said that she was "was bashed in the face and then it
was lights out". They further advised that when Holly was looking in the mirror she stated,
Tommy did this." When asked who hurt her, she wouldn't reply.
When officers attempted to speak to Holly she just repeatedly asked for officers to bring her
son, or she would ask for a mirror to check out her face. She would not explain how she had
received her injuries. When asked if someone did this to her, she would just ask for her son.
I explained to her that Hank was with Rebecca, to which Holly seemed relieved, only to call
Becky" a bitch a few minutes later. Then a few minutes after that, state that she was happy
Hank was with "Auntie Becky"
Despite the fact that we weren't sure what exactly occurred, I gave Holly a domestic violence
form with the report number and asked her if there was a safe place for her to go, to which she
replied her parents lived in town and she could go there.
Ofc. Uribe contacted DCFS and spoke to Tabitha Scott who advised that a report would be
made and a caseworker would respond within 24 hours.
Nothing further at this time.
SLM #354

2015Mendiola
354 11/3/ #Ericson_K|Ericson, Kenneth W|11/5/2015|20:55

Case Report 2015-00068305 Page 2 OF 3

 2015-00068305

Complainant

Adult Waltz, Rebecca, L

19741864

Mobile

English

Other Person

Juvenile Styczykowski, Hank

201453
S UNION St 109/
13/ WWMM

ELGIN, IL 60123

English

2015Mendiola
354 11/3/ #Ericson_K|Ericson, Kenneth W|11/5/2015|20:55

Case Report 2015-00068305 Page 3 OF 3

 zot5 -\"&Jo 5
ELGIN POLICE DEPARTMENT
@copy Jeffrey Swoboda
151 Douglas Avenue Chief of Police
ELG|N, tLLtNO|S 60't20-5503 847 t289-2760

ELGIN
Police Deportment
Consent To Search Cell Phone

Case report number: 2-hl4 - t.8 3O5 Date of Incident:'\)

slh
Incident Type: hrnes*,'c- D'-tu r \ roncr-
Locationoflncident: 53 3- \lnio*--., 5t. 6loin, \ L \€ olL1
hereby $ ant my consent to officers of the Elgin Police
Department and other law enforcement officers assisting them to search the following:

CelI Phone Numberz

Mv cell ohone is described as follows:
Pt r:t^.p t-t
Memory Card:

rrPassword: r4
This is to include any and all data contained within my cell phone.

I declare that I am the occasionaU lusive of this described cell phone. I

further authorize said law enforcement o TClic.
E view any and all electronic
dataSEIZCand
from my cell phone. Whatever data, or items of records, whosever which they deem
pertinent to their investigation, and fully realize said evidence may be used against me in a
Court of Law. Such items may include, but are not limited to:

5,
oY. 6:LA 9r^
h

I understand that I have the right to refuse to consent to the search described above and to
refuse to sign this form. I further state that no promises, threats, force, or physical or mental
coercion of any kind whatsoever have been used to cause me to consent to the search
described above or to sign this form.

oat"' )Vrt r/r5 Time: lO,i at Si

l1
Witness: 2_ Date: lb
Witness: Date:
 2015-00068305

On 11/4/15, I, R/O S. Mendiola #354, responded to the station to assist Ofc. Blomberg #244,
reference the domestic disturbance from the night before. See Ofc. Blomberg's supplement
and my previous general report.
I met up at the station with Ofc. Blomberg who was speaking with Rebecca Waltz (Hank's
paternal aunt) reference her temporary custody of Hank.
Rebecca first advised in summary and not verbatim that she was very concerned for Hank's
safety and advised that both Tom and Holly had substance abuse problems. She advised that
she didn't believe Hank was safe at home and believed that Holly and Tom neglected him and
placed him in unsafe situations.

Mobile

English

Other Person

Juvenile Styczykowski, Hank, M.

201453
S Union St 109/
13/

English

11/3/2015

Case Supplement Report 2015-00068305 Page 1 OF 4

 2015-00068305

On 11/4/15, I, R/O S. Mendiola #354, responded to the station to assist Ofc. Blomberg #244,
reference the domestic disturbance from the night before. See Ofc. Blomberg's supplement
and my previous general report.
I met up at the station with Ofc. Blomberg who was speaking with Rebecca Waltz (Hank's
paternal aunt) reference her temporary custody of Hank.
Rebecca first advised in summary and not verbatim that she was very concerned for Hank's
safety and advised that both Tom and Holly had substance abuse problems. She advised that
she didn't believe Hank was safe at home and believed that Holly and Tom neglected him and
placed him in unsafe situations.
Rebecca went on to say that she had bathed Hank earlier and had discovered various minor
injuries on the baby. She emailed Ofc. Blomberg advising him of such. Then around 0830
hours this morning, she contacted DCFS and spoke to a woman named Janice. Rebecca had
advised of Hank's injuries and that she wanted to take Hank to the hospital for an evaluation.
Rebecca stated that Janice told her that since she was not a parent or guardian, the hospital
wouldn't check him. Janice advised Rebecca that she would have to go to the courthouse to
obtain temporary custody of Hank in order to be able to take him. Rebecca then went to the
courthouse where she sat for several hours before being able to petition her for temporary
custody. She stated that she showed the judge the photos that she had taken the night before
as well as the texts between Holly and her. The judge granted her the temporary
guardianship and in addition signed orders of protection against Holly and Tom.
Later that afternoon she took Hank to Sherman Hospital in Elgin to have him evaluated (See
Ofc. Blomberg's supplement.) In summary, the doctor had advised that he couldn't determine
if the injuries were abuse, there was nothing to indicate that they weren't accidental.
Ofc. Blomberg spoke to Connie from DCFS who advised that Rebecca needed to turn Hank
over to his maternal grandparents, Robert and Sharon Sathern, as they had determined them
to be the appropriate placement in their safety plan.
Both parties (Rebecca and Robert) went to the station, however Robert had to leave
temporarily to take care of his wife, Sharon.
Rebecca showed officers her copies of the orders of protection as well as the petitions, which
copies were made and placed in the records bin. She and Hank were placed in the 2nd floor
family room while the situation was sorted out.
Robert returned and provided officers with his copy of the safety plan from DCFS office, which
a copy was made and placed in the records bin.
Ofc. Blomberg and I showed both the OOP's and the safety plan to Lt. Rafferty who advised
that we would follow the court order at this time.
Later, when talking with Robert, he stated that he and his wife had also gone to the local
DCFS office earlier today and had been told that Hank would be placed with them temporarily
and were given the safety plan then. Robert was advised that Rebecca would be taking Hank
for now, since she had a court order and the next court date would be 11/24/15 at 9am at
KCJC. He was further advised if he didn't want to wait for that court date he could petition the
court for a new order allowing his wife and him custody, but didn't automatically mean that it

2015Mendiola
354 11/3/ #Ericson_K|Ericson, Kenneth W|11/5/2015|20:52

Case Supplement Report 2015-00068305 Page 2 OF 4

 2015-00068305

would be granted. He was given copies of the orders of protection. When asked, Robert
advised that he wasn't aware of any domestic problems between Tom and Holly and stated
that he also wasn't aware of any current substance abuse issues, however stated that his
daughter had a drug problem in the past
Rebecca was informed that Hank would be allowed to leave with her for now. She borrowed
one of the EPD carseats and advised that she would return it after she was able to pick one
up tomorrow.
I left a message for Connie from DCFS to contact me for me to explain the situation.
Nothing further at this time.
SLM #354

2015Mendiola
354 11/3/ #Ericson_K|Ericson, Kenneth W|11/5/2015|20:52
Case Supplement Report 2015-00068305 Page 3 OF 4
 2015-00068305

Other Person

Adult Sathern, Robert

1946254

Cellular Mobile

English

2015Mendiola
354 11/3/ #Ericson_K|Ericson, Kenneth W|11/5/2015|20:52

Case Supplement Report 2015-00068305 Page 4 OF 4

 2015-00068305

On 11-03-15 at about 2151 hours a domestic was dispatched at 53 S. Union. Officers

Uribe, S. Mendiola, and Ramirez were dispatched to 53 S. Union. Elgin Police
Communications dispatched Officer Rosenston and I, Officer Blomberg, to meet with a gray
Durango at Wilcox and Shuler reference the domestic.

Elgin Police Communications (EPC) advised to look for a gray Durango, which I located
upon my arrival to the area of Wilcox and Shuler. A female exited the vehicle identified as
Rebecca Waltz who was with her nephew Hank Styczykowski.

Cellular Mobile

English

Other Person

Juvenile Styczykowski, Hank, M

201453
S Union 109/
13/ WWMM

Elgin, IL 60123

English

11/3/2015

Case Supplement Report 2015-00068305 Page 1 OF 5

 2015-00068305

On 11-03-15 at about 2151 hours a domestic was dispatched at 53 S. Union. Officers

Uribe, S. Mendiola, and Ramirez were dispatched to 53 S. Union. Elgin Police
Communications dispatched Officer Rosenston and I, Officer Blomberg, to meet with a gray
Durango at Wilcox and Shuler reference the domestic.

Elgin Police Communications (EPC) advised to look for a gray Durango, which I located
upon my arrival to the area of Wilcox and Shuler. A female exited the vehicle identified as
Rebecca Waltz who was with her nephew Hank Styczykowski.

Rebecca advised in summary and not verbatim: She was on the phone with her brother
Thomas Ryan who lives at 53 S. Union Elgin, IL. While on the phone with Thomas, Rebecca
heard screaming from Thomas' girlfriend Holly Sathern and heard Thomas and Holly's son,
Hank Styczykowski, crying, and Thomas screaming, "leave the baby sleep". A moment later
the phone went dead. Rebecca was concerned for Hank's welfare so she went to 53 S.
Union, entered Thomas and Holly's residence and observed Thomas holding Hank. Rebecca
observed Holly laying in bed who unresponsive and had blood on her. Rebecca went into the
bathroom and observed blood there. Rebecca pretended that she was calling to order a pizza
but called police instead. Rebecca then took Hank from Thomas and left the residence and
met with police in the area of Wilcox and Shuler.

Rebecca advised Thomas and Holly have been involved in alcohol and drugs between the
two of them. Rebecca advised she took Hank from the house for his safety.

On 11-04-15 Rebecca gave me nine photos, four of which she advised showed Holly and
blood in the residence on Union, and five of which were text messages she received from
Holly and Thomas (a text from Holly saying "I'm dying here I don't know what to do").

While at Wilcox and Shuler, I asked Rebecca if the child was ok to which Rebecca advised
he was ok, and I didn't observe any injuries. Rebecca advised Hank had a little blood splatter
on his face from the blood that was at 53 Union but that he wasn't injured. Officer Rosenston
provided Rebecca a blanket for Hank which she put around him. Officer Rosenston went to
the Elgin Police Department and obtained a vehicle child safety seat and brought it back for
Hank.

On 11-04-15 at the beginning of the afternoon patrol shift, I received a work e-mail from
Rebecca who advised that after she returned home and bathed Hank, she saw a couple
scratches on Hank's neck and a bruise on Hank's forehead. Rebecca attached two pictures of
Hank showing his face and neck. I later submitted Rebecca's e-mail and two pictures into
Elgin Police evidence.

On 11-04-15 I called Rebecca and spoke to her about her e-mail she sent me. Rebecca

2015Blomberg
244 11/3/ #echevarria_e|Echevarria, Eric P|11/11/2015|19:58

Case Supplement Report 2015-00068305 Page 2 OF 5

 2015-00068305

advised DCFS was involved with this incident, she later located the injuries she mentioned in
her e-mail, and that she was en route to Sherman Hospital to have Hank checked out.

I called DCFS and spoke to Connie Stone-Wooten, supervisor in the Elgin DCFS office,
who advised that DCFS was investigating the incident and determined Hank would be turned
over to Hank's grandfather's, Robert Sathern's custody.

I responded to Sherman Hospital and spoke to Rebecca who was with Hank in the
emergency room. Rebecca advised she spoke to DCFS, went to Kane County Court on 11-
04-15 to obtain guardianship of Hank, and received emergency orders of protections against
Thomas Ryan and Holly Stratton (15OP572 and 15OP577 respectively) which gave her
custody of Hank.

With the Nikon D90 camera, I took photos of Hank's injuries with Rebecca present. The
photos show a bruise on Hank's forehead, couple scratches on Hank's front neck, blue color
near Hank's right eye and nose, and red mark on Hank's left thumb.

Hank was examined by Sherman Medical Doctor Mohammad Zaman. I asked Dr.
Mohammad if there injuries consistent with child abuse. Dr. Mohammad advised he couldn't
determine that. Dr. Mohammad advised me there was nothing on Hank to suggest the injuries
were non accidental. Dr. Mohammad advised there was nothing abnormal.

After Hank was released from the Hospital, Rebecca agreed to meet me at the Elgin Police
Department. Connie from DCFS called while in the hospital and advised that Robert Sathern
would be responding to the Elgin Police Department to take custody of Hank.

I responded to the police department and spoke to Officer S. Mendiola about this incident ,
Officer Mendiola being the officer who investigated the domestic incident on Union, on 11-03-
15.

Officer Mendiola and I spoke to Rebecca in the 2nd floor family room of the police
department. Hank's grandfather, Robert Sathern then arrived at the police department at
about 1840 hours on 11-04-15 abd showed Officer Mendiola and I a safety plan from
Department of Children and Family service (DCFS) which indicated Hank would reside with
the maternal grandparents, Robert and Sharon Sathern, at 254 Parkwood Elgin, IL.

Officer Mendiola advised Lt. Rafferty about this incident (court order and safety plan from
DCFS) and Lt. Rafferty advised we'd be following the Kane County Court order and that Hank
would be going to the custody of Rebecca. Officer Mendiola explained to Robert that Hank
would be going to Rebecca's custody per the court order. Rebecca then left the police
department with Hank in her custody.

2015Blomberg
244 11/3/ #echevarria_e|Echevarria, Eric P|11/11/2015|19:58
Case Supplement Report 2015-00068305 Page 3 OF 5
 2015-00068305

2015Blomberg
244 11/3/ #echevarria_e|Echevarria, Eric P|11/11/2015|19:58
Case Supplement Report 2015-00068305 Page 4 OF 5
 2015-00068305

Other Person

Adult Sathern, Robert, L

1946254

Cellular Mobile

English

2015Blomberg
244 11/3/ #echevarria_e|Echevarria, Eric P|11/11/2015|19:58

Case Supplement Report 2015-00068305 Page 5 OF 5

 2015-00068305

Battery11/
3/2015 21:51 Domestic

On 11/04/15, Officer S. Mendiola #354, requested Reporting Detective Carter #332, perform
an extraction of data from a cell phone for a Domestic Disturbance she was investigating. Det.
Carter is the Digital Forensics Examiner for the Elgin Police Department.

Ofc. Mendiola provided contact information for Rebecca Waltz who was the owner of the cell
phone containing the evidence.

Det. Carter called Rebecca Waltz who agreed to bring her cell phone to the Elgin Police
Department for examination on 11/16/15.

On 11/16/15 at approximately 1020 hours, Det. Carter met with Ms. Waltz in the south
interview room in the lobby of the Elgin Police Department located at 151 Douglas Avenue
Elgin, IL.

At 1029 hours, Ms. Waltz signed an Elgin Police Department Consent to Search Cell Phone
form and turned over her following described cell phone:

Manufacturer: Apple
Model: A1522
IMEI: 355876065329058
Serial Number:F2LPN3BWG5QL

Det. Carter digitally photographed the cell phone and downloaded those images to EPD
Digital Evidence storage.

At 1037 hours, Det. Carter performed a logical extraction of data using Cellebrite Physical
Analyzer software version 4.4.0.81, licensed to the Elgin Police Department. Det. Carter
generated a digital report containing communications to/from contacts saved as Holly and
Tommmmmmyass, as well as images after November 3, 2015 0954 hours through November
4, 2015.

Upon completion of the examination, Det. Carter returned the cell phone to Ms. Waltz.

Det. Carter saved all files generated by the examination to the TIU Forensics drive. Det.
Carter saved a copy of the digital report to a 700 MB CD-R and submitted that CD to EPD
Evidence as Evidence Item #3. Det. Carter provided Ofc. S. Mendiola with a copy of the
results. NO FURTHER INFORMATION.

Carter #332 11/3/2015 bisceglie_j|Bisceglie, James|12/3/2015|11:09

Case Supplement Report 2015-00068305 Page 1 OF 2

 2015-00068305

On 11/04/15, Officer S. Mendiola #354, requested Reporting Detective Carter #332, perform
an extraction of data from a cell phone for a Domestic Disturbance she was investigating. Det.
Carter is the Digital Forensics Examiner for the Elgin Police Department.

Ofc. Mendiola provided contact information for Rebecca Waltz who was the owner of the cell
phone containing the evidence.

Det. Carter called Rebecca Waltz who agreed to bring her cell phone to the Elgin Police
Department for examination on 11/16/15.

On 11/16/15 at approximately 1020 hours, Det. Carter met with Ms. Waltz in the south
interview room in the lobby of the Elgin Police Department located at 151 Douglas Avenue
Elgin, IL.

At 1029 hours, Ms. Waltz signed an Elgin Police Department Consent to Search Cell Phone
form and turned over her following described cell phone:

Manufacturer: Apple
Model: A1522
IMEI: 355876065329058
Serial Number:F2LPN3BWG5QL

Det. Carter digitally photographed the cell phone and downloaded those images to EPD
Digital Evidence storage.

At 1037 hours, Det. Carter performed a logical extraction of data using Cellebrite Physical
Analyzer software version 4.4.0.81, licensed to the Elgin Police Department. Det. Carter
generated a digital report containing communications to/from contacts saved as Holly and
Tommmmmmyass, as well as images after November 3, 2015 0954 hours through November
4, 2015.

Upon completion of the examination, Det. Carter returned the cell phone to Ms. Waltz.

Det. Carter saved all files generated by the examination to the TIU Forensics drive. Det.
Carter saved a copy of the digital report to a 700 MB CD-R and submitted that CD to EPD
Evidence as Evidence Item #3. Det. Carter provided Ofc. S. Mendiola with a copy of the
results. NO FURTHER INFORMATION.

2015Carter
332 11/3/ #
bisceglie_j|Bisceglie, James|12/3/2015|11:09

Case Supplement Report 2015-00068305 Page 2 OF 2

1114D015 Hank Styczykorski cordition oice cleaned up. Re:inciden... - Micha6l Blomberg
I f_ (= 92OS
f.1ank Styczykowski condition once cleaned up. Re: incident on S.

Union Street 10-3-15

bntwaltz@gmail.com

Wed ! U4/20r5 12:48 AM

Inbox

to:Michael Blomberg < BLOMBERG_t\4@cityofelgin.org>;

0 a attachments ( 1 vB)

image2.JPG; ATT00001.txt; imagel.JPG; ATT00002.txt;

Once I got home with Hank and bathed him he has a couple of scratches on his neck as well as a bruise that is fairly big
on his forehead. I have included pictures and will be contacting Dcfs on my concerns for this baby in the care of his
parents as well as taking him to a doctor to be checked out. lf you have a case number so that I can share it in the Dcfs
report that would be great. I am truly sorry for this unfortunate situation, but am very glad you guys were there to help
out all involved.
lf you need anything from me please let me know,
Rebecca Waltz

630-923-i0 r1

U4N S05ll m 2LTti M WE4NW F iY U 3N 1t1

http6/orJtt@k.oi1ice365.co.n / q/val#vie\,vm odel= ReadMessagoltern & ltern lD=pAM kiqD kzZTc0\
TJ ILTBhY2YtN D U 9BGA' '
I

1,. \

I a
a
I
Nti- btrar
cFs144r - A
Rev. 4/2013 State of Illinois
Department ofChildren and Family Services

SafefY Plan

A safety plan may only be developed if the safety decision is Unsafe and the supervisor or Area Administrator
has given his or her approval for the development ofthe plan.

Section I - Identifying Information

Case Name: V oilrl 417',ovn Date: I

LlvSCR
CYCIS ID
OT 4^ 27 m Date of Planncd Review:

Type ofPlan: Date Amended:

fl child In-Home Child Oulof-Homc

Section II - Safety Threats

The following marked Safety Threat(s) from the CERAP Safety Assessment have led to the need for a
safety plan:

L f] A Caregiver, paramour or member of the household whose behavior is violent and out of control.

2. D A caregiver, paramour or member ofthe household is suspected ofabuse or neglect that resulted in moderate to severe
harm to a child or who has nrade a plausible threat ofsuch harm to a child.

l. E A caregiver. paramour or member ofthe household has a documented history of perpetrating child abuse/neglect or there
is reasonable cause lo believe that he/she previously abused or neglected a child. The severity ofthe maltreatment,
coupled with the caregiver's failure to prolect, suggests child safety may be an urgent and immediate concem.

4. f] Child sex abuse is suspected and circumstances suggest child safety may be an immediate concerh.

5. D A caregiver, paramour or member of the household is hiding the child, refuses access or lhere is some indication ( hat a
caregiver may fleeing with the child.

6. ! Child is fearful ofhis/her home situation because of the people living in or frequenting the home.

7. f] A caregiver, paramour or member of (he household describes or acts toward the child in a predominantly negative
n'lanner.

8 n A caregiver, paramour or member ofthe household has dangerously unrealistic expectations f\th9 child.

9 n or member of the household expresses credible fear that he/rrr. . 1trt$ ,,.grare ( o severe
ilH::,J:.i,i;:^"ur

10. E A caregiver. paramour or member df the househotd has nor. will not, or is unable i\$or[" rrfu.f,nr,uupervision to
prolect a child fronr potentially moderate to severe harm. I v)
ll.E A caregiver, paramour or member ofthe household refuses to or is unable to meet a child's medQt'bi mental health
care needs and such lack ofcare may result in moderate to severe harm to the child + \"

12. [] A caregrver, paramour or member ofthe household refuses to or is unable lo meet the child')teea for lood. clothing.
shelter, and./or appropriate environmental living conditions.

ll A caregiver, paramour or member ofthe household whose alleged or observed substance abuse may seriously affect

his/her ability to supervise, protect or care for the child.

t4. E A caregiver, paramour or member of the household whose alleged or observed mental/physical illness or developmental
disability may seriously impair or affect his/her ability to provide care for a child.

l5 The presence ofviolence, including domestic violence, that'affects a caregiver's ability lo providf care for a child and/or
H proticrion from moderare ro severe harm
6 d^{
A t( C e C rq , t } S lq A
1
r6. E A caregiver, paramour, member ofthe household 6r other person responsible for a child's welfare engaged in or
credibly alleged to be engaged in human trafficking poses a safety threat of moderate to severe harm to the child.

Page I of3
cFS-t44 t-A
Rev. 4/2013

Section III - Safety Plan

l) What actions have or will be taken to protect each child in relationship to the above-indicated safety tkeat ( sX

l/
I

I-IKW
Ill

2a.rlnl\ 4^J llat

2) Who is responsible for ensuring the safety ofeach child in relationship to the above-indicated safety tkeat(s)?
J

Shua^ ,\ z't-x,ttr, t
i

U i
I'zrn Q lr,a I'-: I-
J
f
rl

i
t

3)What must happen in order for this safety plan to be te:iminated?

I \\ * nl<t r )./, t-J.sttr o kztk -yr^

Dz'r.rnAC. d
1, I a\
u<-
J).
iAt
4A// / t hv(: y'l/zlt,aJ--,

t)

What estimated time frames have been

ssed4 this lan?

Page 2 of 3
cFs l44l-A
Rev. 4/2013

i
Section IV - Signatures

A: I have discussed the attached safety plan and the consequences of non-compliance with the caretaker and all
those who are responsible for carrying out the plan. I hai'e their agreement to abide by the terms and conditions
of the plan. !

Worker's Si alure:
i
LDate ti-------]
Tel e Number trtt -)
Su sor's Name a Tel e

B: We have discussed the safety plan with the worker. { e understand its contents and that it is voluntary. We
agree to abide by the terms and conditions of the plan. If,something happens that prevents us from carrying out
the plan, we will irrunediately notify the worker. If the wbrker is unuruilubl", we witl notify the superviior. We
understand that failure to agree to the plan or to carry ou tlthe plan may result in a reassessment of our home and
possible protective custody and/or State Attomey's Ofiice for a court order to remove my
children from my home. We will then ha to plead our case in court.

Si ture of Parent/ lver: Date:

Si ture of Parent/Care lver: Date:

t,
C: As a Safety Pla[ Partici qant, l understEE{/my rql lnfdrdthe worker/supervisor if I am unable.to
fulfill my obligations to this plan.

AJName:
r3 E Si ture

Role/Rclationshi Date: r
Name: Signatrlic:

Role/Relationship: Date {

Name: Signature:

Role/Relationship Date

E: Supervisor Approval

tr Supervisor verbally approved the plan by telephone.

Name: Date & Time:

S SOI Signa

Signature Date & Time:

Originsl - Case file Copy I - ParenUcaretaker Copy 2- Plan Participants All others will b€ mailed a copy

Page 3 of3