Exhibit 3 "Citation Community Service Program Service Authorization Form (Saf)" - Florida

What Is Exhibit 3?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2014;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Exhibit 3 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download Exhibit 3 "Citation Community Service Program Service Authorization Form (Saf)" - Florida

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STATE OF FLORIDA
AD-XXXX-XX
DEPARTMENT OF JUVENILE JUSTICE
New 1-1-2014
Exhibit 3
CITATION COMMUNITY SERVICE PROGRAM SERVICE AUTHORIZATION FORM (SAF)
I. REQUESTOR/REFERRAL SOURCE
Date of the Request:
Requestor Name:
Circuit:
Contact Person:
Email Address:
Telephone Number:
Fax Number:
II. YOUTH/PARENT/GUARDIAN
INFORMATION-If this SAF is for a group approval Circle Y and proceed to last page
Youth’s Name:
Parent/Guardian’s Name:
Youth Alias:
Relationship:
Youth’s Assessed Risk Level:
Address:
Circuit: Choose an Item
County:
Telephone # (home):
Telephone # (mobile):
III. YOUTH ELIGIBILITY REVIEW
Did a certified law enforcement officer issue a Civil Citation to the youth?
Was a copy of the Civil Citation forwarded to the Department’s Circuit Probation Office
or the Operating Entity
Did the Civil Citation include sanctions issued by the issuing law enforcement officer?
If so, please list.
Did a review of JJIS confirm the youth is eligible for civil citation?
Is the alleged offense a misdemeanor offense?
Has the State Attorney consented to the youth’s referral to a Civil Citation Community Service Program?
Has the youth’s parent(s)/guardian(s) provided his/her consent to participate in the Civil Citation Program?
Does the youth have a mental health/substance need/offense requiring mental health/substance abuse services?
Yes (STOP and complete
Mental Health Screening Referring Form and follow Residential Services procedures.)
No (Continue)
IV. YOUTH ASSESSED NEEDS
Type of Needs Assessment administered
PAT
Other
What are the service needs identified on the PAT/Needs Assessment?
V. REQUEST FOR SERVICES
Contract #
Description of Service
Anticipated
Anticipated
County of
Rate
Estimated $
Begin Date
End Date
Service
Total
PROBATION REVIEW - (To be completed by Probation and Community Intervention HQ)
Page 1 of 2
STATE OF FLORIDA
AD-XXXX-XX
DEPARTMENT OF JUVENILE JUSTICE
New 1-1-2014
Exhibit 3
CITATION COMMUNITY SERVICE PROGRAM SERVICE AUTHORIZATION FORM (SAF)
I. REQUESTOR/REFERRAL SOURCE
Date of the Request:
Requestor Name:
Circuit:
Contact Person:
Email Address:
Telephone Number:
Fax Number:
II. YOUTH/PARENT/GUARDIAN
INFORMATION-If this SAF is for a group approval Circle Y and proceed to last page
Youth’s Name:
Parent/Guardian’s Name:
Youth Alias:
Relationship:
Youth’s Assessed Risk Level:
Address:
Circuit: Choose an Item
County:
Telephone # (home):
Telephone # (mobile):
III. YOUTH ELIGIBILITY REVIEW
Did a certified law enforcement officer issue a Civil Citation to the youth?
Was a copy of the Civil Citation forwarded to the Department’s Circuit Probation Office
or the Operating Entity
Did the Civil Citation include sanctions issued by the issuing law enforcement officer?
If so, please list.
Did a review of JJIS confirm the youth is eligible for civil citation?
Is the alleged offense a misdemeanor offense?
Has the State Attorney consented to the youth’s referral to a Civil Citation Community Service Program?
Has the youth’s parent(s)/guardian(s) provided his/her consent to participate in the Civil Citation Program?
Does the youth have a mental health/substance need/offense requiring mental health/substance abuse services?
Yes (STOP and complete
Mental Health Screening Referring Form and follow Residential Services procedures.)
No (Continue)
IV. YOUTH ASSESSED NEEDS
Type of Needs Assessment administered
PAT
Other
What are the service needs identified on the PAT/Needs Assessment?
V. REQUEST FOR SERVICES
Contract #
Description of Service
Anticipated
Anticipated
County of
Rate
Estimated $
Begin Date
End Date
Service
Total
PROBATION REVIEW - (To be completed by Probation and Community Intervention HQ)
Page 1 of 2
STATE OF FLORIDA
AD-XXXX-XX
DEPARTMENT OF JUVENILE JUSTICE
New 1-1-2014
Exhibit 3
CITATION COMMUNITY SERVICE PROGRAM SERVICE AUTHORIZATION FORM (SAF)
I. YOUTH ELIGIBILITY
Is the youth eligible for the services requested based on (Check the appropriate box.):
Youth meets stated age requirements for services? :
Yes
No
Youth meets parameters regarding the youth’s offense status?
Yes
No
Youth meets the eligibility requirements for the specific services requested?
Yes
No
II. FUNDING AVAILABLE
Is the youth eligible for the services requested based on (Check the appropriate box.):
Youth resides in a county offering the services requested?
Yes
No
Youth meets the eligibility requirements associated with the Program?
Yes
No
III. PROVIDER TO PROVIDE SERVICES TO YOUTH
Contract/Rate Agreement #:
Contact Person Telephone Number:
Provider Name:
Provider Name:
Contact Person:
Contact Person Telephone Number:
Contact Person:
Contact Person Telephone Number:
APPROVAL
Date of the Service Authorization Form Review:
Results of the SAF Review:
SAF Request Approved
SAF Request Denied (provide reason)
(Check the appropriate box.) If denied please provide reason:
Signature:_______________________________________________________
Print Name:______________________________________________________
Title:___________________________________________________________
Date:____________________________ Phone:_________________________
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