Fill and Sign the Dispositional Order Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE INTEREST OF       Name Dispositional Order - Protection or Services (Chapter 48)       Date of Birth Case No.       A petition was filed with the court. This dispositional hearing was held on       , which is the effective date of this order. THE COURT FINDS: 1. The child is in need of protection or services because: Ct Description Wisconsin Statutes Plea Date of Petition                                                                                     2. The child is placed out of the home. a. Placement in the home at this time is contrary to the child’s welfare because:       b. Reasonable efforts to prevent removal were: (Complete one of the following.) made by the department or agency responsible for providing services in the following manner:       made by the department or agency responsible for providing services, although an emergency situation resulted in immediate removal of the child from the home.       not required under §48.355(2d) because:       required, but good cause has been shown why sufficient information is not available to enable the court to make the necessary findings. This hearing is continued until (date):       . not to exceed 5 days required, but the department or agency responsible for providing services failed to make reasonable efforts. JC-1611, 08/06 Dispositional Order - Protection or Services (Chapter 48) §§48.345, 48.355, 48.356, Wisconsin Statutes . This form shall not be modified. It may be supplemented with additional material. Page 1 of 4 Dispositional Order - Protection or Services (Chapter 48) Page 2 of 4 Case No. c. Permanency plan has not been filed. has been filed and reasonable efforts to achieve the goal(s) of the permanency plan were: (Complete one of the following only if a permanency plan has been filed.) made by the department or agency responsible for providing services in the following manner:       not made by the department or agency responsible for providing services. d. The parents have been advised of the applicable grounds for termination of parental rights and the conditions that are necessary for the return of the child to the home or restoration of visitation rights. 3. As to the department or agency recommendation: a. The placement location recommended by the department or agency is adopted. OR b. After giving bona fide consideration to the recommendations of the department or agency and all parties, the placement location recommended is not adopted. 4. The provisions of the Indian Child Welfare Act do not apply. have been followed. 5. Other:       THE COURT ORDERS: 1. The child is placed under court jurisdiction. 2. Placement: In home at:       Expiration date of this order:       not to exceed 1 year Out of home at:       Expiration date of this order shall be the later of:  One year from the date of this order, or  The date the child reaches his or her 18 th birthday, or  The date the child reaches his or her 19 th birthday if the child is enrolled fulltime in a secondary school or vocational or technical equivalent and reasonably expected to complete the program prior to age 19. OR Expiration date of this order:       . 3. This is an out of home placement and the permanency plan shall be filed no later than 60 days from the date of the child’s removal from the home. 4. Conditions of supervision and/or return: See attached.       JC-1611, 08/06 Dispositional Order - Protection or Services (Chapter 48) §§48.345, 48.355, 48.356, Wisconsin Statutes . This form shall not be modified. It may be supplemented with additional material. Page 2 of 4 Dispositional Order - Protection or Services (Chapter 48) Page 3 of 4 Case No. 5. Services to be provided to child and family: See attached.       6. Agency/person responsible for supervision/services/case management:       7. Legal custody transferred to: County Department of Human/Social Services Wisconsin Department of Health and Family Services Other:       8. Special treatment or care:       9. If the child is placed outside of the home, the parent(s) shall provide a statement of income, assets, debts, and living expenses, to the county department or agency. a. The parent(s)/guardian shall contribute toward the expenses of custody/services in the amount of: $       to be determined by (agency)       b. The amount of support to be paid by the parent(s), guardian or trustee for the out-of-home placement is: $       or       % of gross income payable by wage assessment. to be set by the child support agency. The support obligation begins on the date of placement. 10. For an out of home placement, written TPR warnings are attached. 11. Other:       Distribution: 1. Original - Court 2. Child/Guardian ad Litem 3. Parents/Guardian/Legal Custodian 4. Attorney(s) 5. Social Worker/Agency Staff Person 6. Foster Home/ Physical Custodian 7. District Attorney/Corporation Counsel 8. Court Appointed Special Advocate 9. Other:       BY THE COURT: Circuit Court Judge       Name Printed or Typed       Date JC-1611, 08/06 Dispositional Order - Protection or Services (Chapter 48) §§48.345, 48.355, 48.356, Wisconsin Statutes . This form shall not be modified. It may be supplemented with additional material. Page 3 of 4 JC-1611 , 06/03 Dispositional Order - Protection or Services (Chapter 48) §§48.345, 48.355, 48.356, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 3