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IN THE CIRCUIT COURT OF THE
ECO 141) JUDICIAL CIRCUIT IN
AND FOR 61,001>S1)Fpd COUNTY FLORIDA.
CASE NUMBER: ZOL
0) , LF-V0f i ZR. 010J- 306.179 CFIT,13
PRINT YOUR NAME)
Post Office Box 1000
Chattahoochee, Florida 32324-1000
vs.
John Polisknowski, as the Hospital Administrator C,-
of the Florida State Hospital, and
Shevaun Harris, as Secretary
CO
of the Department of Children and
Family Services.
Respondents.
- PETITION FOR WRIT OF HABEAS CORPUS
COMES NOW Rigyp4014 LE.31j6:R,,and, petition this Honorable
Court for a Writ of Habeas Corpus and would show:
1. This Court has jurisdiction over this cause under the
provisions of Sections 916.107 (9)(a) and 916.16, Florida Statutes.
Section 916.16, Florida Statutes, provides that no person who has been
committed for hospitalization pursuant to the provisions of Chapter
916 can be released "except by order of the committing court".
Therefore, only this Court can possibly afford me the relief that I am
-seeking—herein, unless---this Court-relinquishes-its jurisdiction- over--
me and agrees for the Circuit Court in the county where I am
hospitalized to have the authority to release me.
2. I was sent against my will to the Florida State Hospital at
Chattahoochee, Gadsden County, Florida on 07 11 X I ti20g3 '
/ by Order
of the Circuit Court in and for VOLUg/ County, Florida.
1
3. I am being kept here against my will by John Polisknowski, as
the Hospital Administrator of the Florida State Hospital, and by
Shevaun Harris, as Secretary of the Florida Department of Children and
Family Services.
4. I believe that I am being deprived of my freedom for wrong
and illegal reasons.
5. I believe that depriving me of my freedom is illegal or wrong
because: (State the facts and reasons that make your commitment
illegal or wrong. Be as specific as possible. Attach additional
sheets, if necessary.)
R.) r uadlo F/10-1"i`ii• eoh5h/u17 anj,egkhrcie 2T
) _ssec'oi,
I Pray -Phe 1-IDA0gAgi-E cnigy-- 4-d on m
- (10phi rear;
U 47) lit.#2- '*1
via S (0(YeSid oh ()Y- (211)50f- FOiwkimy 6.1, Qoaci) ol(v.-
-10 AIs2_ sdalepx/S---nindo, by aYorhekchva- 5,41 criovo-E
r 4-1-104 her) vdii4:01 iS 1A5. M - 75-(V)1E 6-0 6-E
yniN.S 1(e ksel,ded 4-4Fe WeS1- 1 -i9VaW04) 9) &dee rni (Awe)
jay z7e 07 ki V7403(3rbel, W, )ivreinis)8
e ttiai'VedinNt SP-e0dy Wiat 1.4y ) ply 14)7.1 al)?Pa 'ITC?4047 1'5;1,1
If}91011 )
k Layt Me cot for' reAg )
6. I am unable to afford an attorney. Pv5 rnaiier
--WHEREFORE, I respectfully-request that-this -Honorable Court:- ---
A. Enter an Order authorizing my release from involuntary
hospitalization at the Florida State Hospital, or
B. Issue a Writ of Habeas Corpus commanding John Polisknowski as
the Hospital Administrator of the Florida State Hospital, to bring me
in person to this Honorable Court for a hearing on this Petition, and
C. Appoint the Office of the Public Defender or another attorney to
represent me in this matter, and
D. For such other relief as the nature of this matter may require.
I SWEAR OR AFFIRM that the above stated matter(s) are true and
correct to the best of my knowledge, information, and belief.
tIT/101(4 Le vs}()
(SIGN OUR NAME)
STATE OF FLORIDA )
SS
COUNTY OF GADSDEN )
BEFORE ME, the undersigned authority, personally appeared the
individual who has signed in my presence after being duly sworn and
cautioned of the penalties of perjury for making knowingly false
statements in the foregoing document. This individual's identity has
been verified by me through:
Personal knowledge or
Sworn statement of a credible witness,
which is attached hereto; or
V / Production of identifying document: (list)
SWORN TO AND SUBSCRIBED before me this .0- day of ‘. ._(_1(2 , 20
NOTARY PUBLIC TATE OF FLORIDA
Print Name: \O-rfTh
My Commission Expires:
.............•', TAMMi' BROWN
1.40• .,"J,. .4-:..„-- Commission # GG 942835
f.f .,,iivi!
'."
• • .E.V
.....!..2•F,FN
•:
... ....za, ...:11 Expires April 27, 2024
..• Bonded Thru Troy Fain Insurance 800-385-7019
3
STATE OF FLORIDA )
SS
COUNTY OF GADSDEN )
AFFIDAVIT OF INDIGENCY
THE UNDERSIGNED AFFIANT states that due to Indigence, he or she is
unable to pay the charges otherwise due to the Court, the Clerk of the Court, or to the
Sheriff, for bringing of this Petition for Writ of Habeas Corpus, and further states that to
the best of the Affiant's belief and knowledge, he or she is fully entitled to the relief
sought.
•
/5y/Vics
AFFIANT (SIGN YOUR NAME)
BEFORE ME, the undersigned authority, this day personally appeared the
Affiant who signed above in my presence and swears after being duly sworn and
cautioned that the statements made above are true and correct to the best of his or her
belief and knowledge. The Affiant's identity was verified by me through:
Personal knowledge; or
Sworn state of credible witness,
which is attached hereto; or
/Prod tioklof ident ing document: (List)
DATED this ,-. .Pclay of , 2()D
NOTARY PUBL STATE OF FLORIDA
Print Name: Vircm
My Commission Expires:
•'" ' TAMMY BROWN
Conimission # GG 942835
.7.417.-,;§7 Expires April 27, 2024
•' Bonded Thru Troy Fain Insurance 19
,?::1-)
FSIDENTADVOCACY,OFRCE'!„
Department JACKSONVILLE FL 329EoposT FIRST-CLASS MAIL
Attn: FLORIDA
4 3Arsj - PM 3 L 01/04/2024
FLORIDA STATE HOSPITAL
s Ar-
291 74$000.632
PO BOX 1000 HOSPITAL
CHATTAHOOCHEE, FLORIDA 32324-1000 ZIP 32324
041M11465974
Clerk of Circuit Court & Comptroller
P.O. Box 6043
Deland, FL. 32721-6043
;3272. i —604343 lit if III pi 1 11111111 III III I lII I lin
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IN THE CIRCUIT COURT OF THE ECO 141) JUDICIAL CIRCUIT IN AND FOR 61,001>S1)Fpd COUNTY FLORIDA. CASE NUMBER: ZOL 0) , LF-V0f i ZR. 010J- 306.179 CFIT,13 PRINT YOUR NAME) Post Office Box 1000 Chattahoochee, Florida 32324-1000 vs. John Polisknowski, as the Hospital Administrator C,- of the Florida State Hospital, and Shevaun Harris, as Secretary CO of the Department of Children and Family Services. Respondents. - PETITION FOR WRIT OF HABEAS CORPUS COMES NOW Rigyp4014 LE.31j6:R,,and, petition this Honorable Court for a Writ of Habeas Corpus and would show: 1. This Court has jurisdiction over this cause under the provisions of Sections 916.107 (9)(a) and 916.16, Florida Statutes. Section 916.16, Florida Statutes, provides that no person who has been committed for hospitalization pursuant to the provisions of Chapter 916 can be released "except by order of the committing court". Therefore, only this Court can possibly afford me the relief that I am -seeking—herein, unless---this Court-relinquishes-its jurisdiction- over-- me and agrees for the Circuit Court in the county where I am hospitalized to have the authority to release me. 2. I was sent against my will to the Florida State Hospital at Chattahoochee, Gadsden County, Florida on 07 11 X I ti20g3 ' / by Order of the Circuit Court in and for VOLUg/ County, Florida. 1 3. I am being kept here against my will by John Polisknowski, as the Hospital Administrator of the Florida State Hospital, and by Shevaun Harris, as Secretary of the Florida Department of Children and Family Services. 4. I believe that I am being deprived of my freedom for wrong and illegal reasons. 5. I believe that depriving me of my freedom is illegal or wrong because: (State the facts and reasons that make your commitment illegal or wrong. Be as specific as possible. Attach additional sheets, if necessary.) R.) r uadlo F/10-1"i`ii• eoh5h/u17 anj,egkhrcie 2T ) _ssec'oi, I Pray -Phe 1-IDA0gAgi-E cnigy-- 4-d on m - (10phi rear; U 47) lit.#2- '*1 via S (0(YeSid oh ()Y- (211)50f- FOiwkimy 6.1, Qoaci) ol(v.- -10 AIs2_ sdalepx/S---nindo, by aYorhekchva- 5,41 criovo-E r 4-1-104 her) vdii4:01 iS 1A5. M - 75-(V)1E 6-0 6-E yniN.S 1(e ksel,ded 4-4Fe WeS1- 1 -i9VaW04) 9) &dee rni (Awe) jay z7e 07 ki V7403(3rbel, W, )ivreinis)8 e ttiai'VedinNt SP-e0dy Wiat 1.4y ) ply 14)7.1 al)?Pa 'ITC?4047 1'5;1,1 If}91011 ) k Layt Me cot for' reAg ) 6. I am unable to afford an attorney. Pv5 rnaiier --WHEREFORE, I respectfully-request that-this -Honorable Court:- --- A. Enter an Order authorizing my release from involuntary hospitalization at the Florida State Hospital, or B. Issue a Writ of Habeas Corpus commanding John Polisknowski as the Hospital Administrator of the Florida State Hospital, to bring me in person to this Honorable Court for a hearing on this Petition, and C. Appoint the Office of the Public Defender or another attorney to represent me in this matter, and D. For such other relief as the nature of this matter may require. I SWEAR OR AFFIRM that the above stated matter(s) are true and correct to the best of my knowledge, information, and belief. tIT/101(4 Le vs}() (SIGN OUR NAME) STATE OF FLORIDA ) SS COUNTY OF GADSDEN ) BEFORE ME, the undersigned authority, personally appeared the individual who has signed in my presence after being duly sworn and cautioned of the penalties of perjury for making knowingly false statements in the foregoing document. This individual's identity has been verified by me through: Personal knowledge or Sworn statement of a credible witness, which is attached hereto; or V / Production of identifying document: (list) SWORN TO AND SUBSCRIBED before me this .0- day of ‘. ._(_1(2 , 20 NOTARY PUBLIC TATE OF FLORIDA Print Name: \O-rfTh My Commission Expires: .............•', TAMMi' BROWN 1.40• .,"J,. .4-:..„-- Commission # GG 942835 f.f .,,iivi! '." • • .E.V .....!..2•F,FN •: ... ....za, ...:11 Expires April 27, 2024 ..• Bonded Thru Troy Fain Insurance 800-385-7019 3 STATE OF FLORIDA ) SS COUNTY OF GADSDEN ) AFFIDAVIT OF INDIGENCY THE UNDERSIGNED AFFIANT states that due to Indigence, he or she is unable to pay the charges otherwise due to the Court, the Clerk of the Court, or to the Sheriff, for bringing of this Petition for Writ of Habeas Corpus, and further states that to the best of the Affiant's belief and knowledge, he or she is fully entitled to the relief sought. • /5y/Vics AFFIANT (SIGN YOUR NAME) BEFORE ME, the undersigned authority, this day personally appeared the Affiant who signed above in my presence and swears after being duly sworn and cautioned that the statements made above are true and correct to the best of his or her belief and knowledge. The Affiant's identity was verified by me through: Personal knowledge; or Sworn state of credible witness, which is attached hereto; or /Prod tioklof ident ing document: (List) DATED this ,-. .Pclay of , 2()D NOTARY PUBL STATE OF FLORIDA Print Name: Vircm My Commission Expires: •'" ' TAMMY BROWN Conimission # GG 942835 .7.417.-,;§7 Expires April 27, 2024 •' Bonded Thru Troy Fain Insurance 19 ,?::1-) FSIDENTADVOCACY,OFRCE'!„ Department JACKSONVILLE FL 329EoposT FIRST-CLASS MAIL Attn: FLORIDA 4 3Arsj - PM 3 L 01/04/2024 FLORIDA STATE HOSPITAL s Ar- 291 74$000.632 PO BOX 1000 HOSPITAL CHATTAHOOCHEE, FLORIDA 32324-1000 ZIP 32324 041M11465974 Clerk of Circuit Court & Comptroller P.O. Box 6043 Deland, FL. 32721-6043 ;3272. i —604343 lit if III pi 1 11111111 III III I lII I lin