Statement of Emergency Protective Placement

This form is used to state that a person has been taken into custody for an Emergency Protective Placement. It requires the person filling it out to identify who they are and explain why the person needs immediate protective placement.

The court describes it as: To state that an individual has been taken into custody for Emergency Protective Placement.

Official instructions

How-to guides published by the court for this form.

• Plain-language summary↗

Common questions

Who fills out this form?

The form must be filled out by a sheriff, police officer, firefighter, guardian, or another authorized representative listed on the form.

What does this form ask for?

It asks for details about the person who was placed in custody, when and where they were detained, and the reasons for the emergency placement.

Revision history

No changes recorded since we started tracking this form on October 10, 2026. The current version took effect November 19, 2021.

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