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IN THE CIRCUIT COURT OF JACKSON COUNTY, MISSOURI
Plaintiff Defendant Case Number
Attorney Name, Address, Bar#
VERIFICATION OF COMPLIANCE WITH CENTERS FOR DISEASE CONTROL AND PREVENTION
ORDER TITLED “TEMPORARY HALT IN RESIDENTIAL EVICTIONS TO PREVENT THE FURTHER
SPREAD OF COVID-19
NOW COMES the Plaintiff and states as follows:
The plaintiff is seeking to recover possession of the following described premises:
The undersigned has reviewed the Order titled “Temporary Halt in Residential Evictions to Prevent the Further Spread
of COVID-19” issued by the Centers for Disease Control under Section 361 of the Public Health Service Act and
hereby certifies:
I have not received an executed copy of a Declaration Form from any of the tenants, lessees, or residents that I am
seeking to remove; OR
The Order authorizing eviction in this case is based on the tenant, lessee, or resident engaging in criminal activity
while on the premises; OR
The Order authorizing eviction in this case is based on the tenant, lessee, or resident threatening the health or
safety of other residents; OR
The Order authorizing eviction in this case is based on the tenant, lessee, or resident damaging or posing an
immediate and significant risk of damage to property; OR
The Order authorizing eviction in this case is based on the tenant, lessee, or resident violating an applicable
building code, health ordinance, or similar regulation relating to health and safety; OR
The Order authorizing eviction in this case is based on the tenant, lessee, or resident violating another contractual
obligation other than the timely payment of rent or similar housing-related payment (including non-payment or late
payment of fees, penalties, or interest).
I declare under the penalties of perjury that this verification has been examined by me and that its contents are true
to t
he best of my information, knowledge, and belief. I FURTHER DECLARE, UNDER PENALTIES OF
PERJURY, THAT I HAVE PROVIDED AN EXECUTED COPY OF THIS VERIFICATION TO ALL
TENANTS, LESSEES OR RESIDENTS THAT I AM SEEKING TO REMOVE.
NOTICE TO TENANTS, LESSEES OR RESIDENTS – IF YOU CONTEST THE ACCURACY OF THE
STATEMENTS IN THIS VERIFICATION, YOU MUST FILE A MOTION/NOTICE WITH THE COURT, IN
THE CASE NUMBER STATED ABOVE, WITHIN SEVEN (7) DAYS OF RECEIVING THIS
VERIFICATION. IF NO MOTION/NOTICE IS FILED, THE COURT MAY PROCEED WITH EVICTION
BASED ON THE STATEMENTS IN THIS VERIFICATION.
Date Plaintiff/Attorney
