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JD-1746, 02/17 Dispositional Order - Protection or Services (Chapter 938) §§ 938.78(2)(ag) and (aj), 938.34, 938.345, 938.355 and 938.396(2g)(m), W isconsin Statutes This form shall not be modified. It may be supplemented with additional ma terial. Page 1 of 4 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY For Official Use IN THE INTEREST OF Name Dispositional Order - Protection or Services (Chapter 938) Date of Birth Case No. A petition has been filed with the court. This dispositional hearing was held on [Date] , which is the effective date of this order. THE COURT FINDS: 1. The juvenile is in need of protection or services because the juvenile is uncontrollable. habitually truant from home. habitually truant from school. a school dropout. as a result of the juvenile’s intentional refusal to attend school rather than the failure o f any other person. under the age of 10 and committed a delinquent act. determined to be not responsible by reason of mental disease or defect. determined to be not competent to proceed. 2. The provisions of the Indian Child W elfare Act do not apply . An inquiry has been made on the record to each participant in this proceeding as to whether the participant knows or has reason to know that the juv enile is an Indian child. (For an Indian juvenile who is placed out- of-home, use the Indian Child Welfare Act version [IW-1746] of th is order.) 3 . The juvenile is placed out of the home. A. Placement in the home at this time is is not contrary to the welfare of the juvenile and the communi ty. B. Reasonable efforts to prevent removal were [Complete one of the following] made by the department or agency responsible for providing services as follows: made by the department or agency responsible for providing services, although an emergency situat ion resulted in immediate removal of the juvenile from the home as follows: required, but the department or agency responsible for providing services failed to make reas onable efforts. C. Reasonable efforts to place the juvenile in a placement that enables the sibling group to remain t ogether were made. not required because the juvenile does not have siblings in out-of -home care. not required because it would be contrary to the safety or well being of the juvenile or any of the siblings. D. Permanency plan was not filed. filed and reasonable efforts to achieve the permanency goal of the permanency p lan, including through an out- of-state placement if appropriate, were Dispositional Order - Protection or Services (Chapter 938) Page 2 of 4 Case No. JD-1746 , 02/17 Dispositional Order - Protection or Services (Chapter 938) §§93 8.78(2)(ag) and (aj), 938.34, 938.345, 938.355 and 938.396(2g)(m), W isconsin Statutes This form shall not be modified. It may be supplemented with additional mater ial. Page 2 of 4 [Complete one of the following only if a permanency plan wa s filed] made by the department or agency responsible for providing services: not made by the department or agency responsible for providing services. E. Parent #1 Parent #2 was present and was asked to provide the names and other identifying information of three adult relatives of the juvenile or other adult individuals whose home t he parent requests the court to consider as placements for the juvenile, unless that information was prev iousl y provided. 4 . As to t he 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 a ll parties, the placement location recommended is not adopted. 5. Participation in the Teen Court program will likely benefit the juvenile and the comm unity and the juvenile has not successfully completed a Teen Court program in the two years before the date of the violatio n. 6. The rehabilitation and treatment/care of the juvenile cannot be accomplished by means of volunta ry consent of the parent(s)/guardian, and the transfer of legal custody is necessary. 7. Restitution. A. The juvenile alone is financially able to pay restitution of $ and/or a forfeiture of $ . B. The juvenile is physically able to perform services for the victim [Under age 14, 40 hour limit] and the victim agrees to accept such services. C. The custodial parent(s) is financially able to pay reasonable restitution of $ and/or a forfeiture of $ . 8. The Statement of Guardian ad Litem was filed. 9. Other: THE COURT ORDERS: 1. The juvenile is placed under court jurisdiction. 2. Placement. In -home at . Expiration date of this order [Not to exceed 1 year] . Out- of-home at and into the placement and care responsibility of the department in the county where this order is iss ued, which has primary responsibility for providing services. Unless otherwise specified, the expiration date of this order shall be the later of the f ollowing:  One year from the date of this order;  The date the juvenile reaches his or her 18 th birthday;  The date the juvenile is granted a high school or high school equivalency diploma or the da te the juvenile reaches his or her 19 th birthday, whichever occurs first, if the juvenile is enrolled fulltime in a secondary school or vocational or technical equivalent and reasonably expected to complete the program prior to age 19;  The date the juvenile is granted a high school or high school equivalency diploma or the da te the juvenile reaches his or her 21 st birthday, whichever occurs first, if ALL of the following apply: Dispositional Order - Protection or Services (Chapter 938) Page 3 of 4 Case No. JD-1746 , 02/17 Dispositional Order - Protection or Services (Chapter 938) §§93 8.78(2)(ag) and (aj), 938.34, 938.345, 938.355 and 938.396(2g)(m), W isconsin Statutes This form shall not be modified. It may be supplemented with additional mater ial. Page 3 of 4  The juvenile is a fulltime student in secondary school or vocational or technical equiv alent.  An individualized education program is in effect for the juvenile.  The juvenile or guardian, on behalf of the juvenile, agrees to this order.  The juvenile is 17 years of age or older when this order is entered. OR Expiration date of this order . 3. This is an out- of-home placement. The juvenile has one or more siblings in out- of-home care and the juvenile is not placed with all those siblings. The department or agency shall make reasonable efforts to provide frequent visitation or other ongoing interaction between the juvenile and any siblings. is not required to provide for frequent visitation or other ongoing interaction because it wou ld be contrary to the safety or well being of the juvenile or any siblings. 4. This is an out- of-home placement and the department or agency shall conduct a diligent search in order to locate and provide notice as required by §938.355(2)(cm), Wis. Stats., to all adult r elatives of the juvenile, including the three adult relatives provided by the parents under §938.335(6) Wis. Stats., no l ater than 30 days from the date of the juvenile’s removal from the home, unless the search was previously conducted and notice provided. 5. This is an out- of-home placement. If a permanency plan has been prepared, filed and is consistent with this order, this order contains the plan. Otherwise, a permanency plan consistent with the court’s order shall be filed no later than 60 days from the date of the juvenile ’s removal from the home and shall be made part of this order. 6. Total restitution is $ . $ , [U nder age 14, $250 limit] to be paid See restitution supplement Make repairs or provide services agreeable to the victim [Under age 14, 40 hour limit] The juvenile is in an out- of-home placement and receiving income; the juvenile shall pay % of that income for restitution. 7. Costs of $ , [Age 14 and over] to be paid . 8. Legal custody transferred to County Department of Human/Social Services. Other: 9. Conditions of supervision and/or return. See attached 10 . If the juvenile 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 am ount 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. 11. Driver’s license suspension or revocation for [Period of time] . (Habitual truancy only) Dispositional Order - Protection or Services (Chapter 938) Page 4 of 4 Case No. JD-1746 , 02/17 Dispositional Order - Protection or Services (Chapter 938) §§93 8.78(2)(ag) and (aj), 938.34, 938.345, 938.355 and 938.396(2g)(m), W isconsin Statutes This form shall not be modified. It may be supplemented with additional mater ial. Page 4 of 4 12. Specific services to be provided to juvenile and family. See attached 13 . The appointment of the guardian ad litem for the juvenile is terminated until further order of the court. is continued to allow the guardian ad litem to perform any of the duties under §938.23 5(4), W is. Stats. is continued for the following purpose(s): 14 . The appointment of the attorney for the Parent #1 Parent #2 Other: terminates until further order of the court. Parent #1 Parent #2 Other: is continued through the term of this order. Parent #1 Parent #2 Other: is continued for the following purpose(s): 15. If the juvenile is placed out of the home, the parent(s) who appeared in court have been orally advis ed of the applicable grounds for termination of parental rights (TPR) and the conditions that are necess ary for the juvenile to be returned to the home or restoration of visitation rights. Written TPR warnings are attach ed. Conditions for return/visitation are part of this order or attached. 16. If any party to this proceeding receives subsequent information that provides reason to know t hat the juvenile is an Indian child, they shall inform the court. 17. Other: The juvenile was advised of possible sanctions for violations of the conditions of th is order. THIS IS A FINAL ORDER FOR PURPOSE OF APPEAL IF SIGNED BY A CIRCUIT COURT JUDGE. BY THE COURT: DISTRIBUTION: 1. Court 2. Juvenile 3. Juvenile’s Parents/Guardian/Legal Custodian/Trustee 4. Juvenile’s Attorney 5. District Attorney/Corporation Counsel 6. Social Worker 7. Other: Circuit Court Judge Circuit Court Commissioner Name Printed or Typed Date NOTICE: If requested by a parent/guardian/legal custodian or the juvenile (14 years of age or over), the agency providing care or services for the juvenile or that has legal custody of the juvenile must disclose to, or make a vailable for inspection, the contents of any records kept or information received by the agency about the j uvenile unless the agency determines that imminent danger would result.