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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 was filed with the court. This dispositional hearing was held on       , 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 of 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 juvenile is placed out of the home. a. Placement in the home at this time is contrary to the welfare of the juvenile and the community 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:       not possible due to the following emergency situation:       not required under §938.355(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. 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. JD-1746 , 06/03 Dispositional Order - Protection or Services (Chapter 938) §§938.34, 938.345, 938.355, 938.396(7)(a), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Dispositional Order - Protection or Services (Chapter 938) Page 2 of 4 Case No. 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. That participation in the Teen Court program will likely benefit the juvenile and the community and the juvenile has not successfully completed a Teen Court program in the two years before the date of the violation. 6. The rehabilitation and treatment/care of the juvenile cannot be accomplished by means of voluntary consent of the parent/guardian, and the transfer of legal custody is necessary. 7. Total restitution is $       , and 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 is financially able to pay reasonable restitution of $       and/or a forfeiture of $       . 8. 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:       Expiration date of this order shall be the later of:  One year from the date of this order, or  The date the juvenile reaches his or her 18 th birthday, or  The date the juvenile reaches his or her 19 th birthday 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. 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 juvenile’s removal from the home. 4. Restitution: $       (under 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):       JD-1746 , 06/03 Dispositional Order - Protection or Services (Chapter 938) §§938.34, 938.345, 938.355, 938.396(7)(a), 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 938) Page 3 of 4 Case No. The juvenile is in an out of home placement and receiving income; the juvenile shall pay       % of that income for restitution. 5. Costs of (age 14 and over) $       , to be paid:       6. Legal custody transferred to: County Department of Human/Social Services Wisconsin Department of Health and Family Services Other:       7. Conditions of supervision and/or return: See attached.       8. 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 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. 9. Driver’s license suspension or revocation for (period of time):       ( Habitual truancy only. ) 10. Services to be provided to juvenile and family: See court report.       11. Agency/person responsible for supervision/services/case management:       12. If the juvenile is placed out of home, 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. Written TPR warnings are attached. 13. Other:       The juvenile was advised of possible sanctions for violations of the conditions of this order. JD-1746 , 06/03 Dispositional Order - Protection or Services (Chapter 938) §§938.34, 938.345, 938.355, 938.396(7)(a), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 4 Dispositional Order - Protection or Services (Chapter 938) Page 4 of 4 Case No. Distribution: 1. Original - Court 2. Juvenile 3. Juvenile’s Parents/Guardian/Legal Custodian/Trustee 4. District Attorney/Corporation Counsel 5. Social Worker 6. Other:       BY THE COURT: Circuit Court Judge       Name Printed or Typed       Date JD-1746 , 06/03 Dispositional Order - Protection or Services (Chapter 938) §§938.34, 938.345, 938.355, 938.396(7)(a), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 4 of 4