Fill and Sign the Terminate Parental Rights Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use Notice Concerning Grounds To Terminate Parental Rights Case No.       Your parental rights can be terminated against your will under certain circumstances. A list of potential grounds to terminate a parent's rights is given below. Those that are check-marked may be most applicable to you, although you should be aware that if any of the others also exist now or in the future, your parental rights can be taken from you. Abandonment. Any of the following must be proven by evidence that: You have left your child without provision for care or support: and neither parent has been found for 60 days. in a place or manner that exposes the child to substantial risk of great bodily harm or death. You have failed to visit or communicate with your child for: three months or longer after your child has been placed, or continued in a placement, outside your home by a court order. six months or longer after leaving the child with any person, and you know or could discover the whereabouts of the child. A court of competent jurisdiction previously has found that when your child was under one year of age: your child was abandoned, pursuant to §48.13(2), Wis. Stats., or a comparable state or federal law. you intentionally abandoned the child in a place where the child may suffer because of neglect, in violation of §948.20, Wis. Stats., or a comparable state or federal law. Continuing Need of Protection or Services. As proven by evidence that: A court placed, or continued in a placement, your child outside your home after a judgment that your child is in need of protection or services under §§48.345, 48.357, 48.363, 48.365, 938.345, 938.357, 938.363, or 938.365, Wis. Stats., and: • The agency responsible for the care of the child has made a reasonable effort to provide the services ordered by the court; • Your child has been outside your home for a cumulative total period of six months or longer under a court order; • You have failed to meet the conditions established for the safe return of the child to your home; and, • There is a substantial likelihood that you will not meet these conditions within the 9-month period following the fact-finding hearing under §48.424, Wis. Stats. A court has adjudicated your child in need of protection or services on three or more occasions, under § 48.13(3), (3m), (10) or (10m) and: • In connection with these adjudications, the court has placed your child outside your home pursuant to a court order containing this notice, and, • You caused the conditions that led to each of the out-of-home placements. Continuing Need of Protection or Services (Unborn child). As proven by evidence that: • A court placed you (as an expectant mother), or continued you in a placement, outside your home after a judgment that your unborn child is in need of protection and services under §§48.345 and 48.347, Wis. Stats. • The agency responsible for the care of you and your unborn child has made a reasonable effort to provide the services ordered by the court; • The child stayed outside your home for a cumulative total period of six months or longer under a court order (not including time spent outside the home as an unborn child); • You have failed to meet the conditions established for the safe return of the child to your home; and, • There is a substantial likelihood that you will not meet these conditions within the 9-month period following the fact-finding hearing under §48.424, Wis. Stats. Failure to Assume Parental Responsibility. As proven by evidence that: JD-1753 , 04/07 Notice Concerning Grounds To Terminate Parental Rights §§48.356, 48.415 and 938.356, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 Notice Concerning Grounds To Terminate Parental Rights Page 2 of 2 Case No. • You are or may be a parent of a child. • You have not had a substantial parental relationship with the child. Continuing Parental Disability. As proven by evidence that: • You are presently an inpatient at a hospital as defined in §50.33(2)(a),(b) or (c), Wis. Stats., a licensed treatment facility as defined in §51.01(2), Wis. Stats., or state treatment facility as defined in §51.01(15), Wis. Stats., on account of mental illness as defined in §51.01(13)(a) or (b),Wis. Stats., or developmental disability as defined in §55.01(2) or (5), Wis. Stats. • You have been an inpatient for at least two of the last five years before a petition to terminate parental rights is filed. • Your condition is likely to continue indefinitely. • Your child is not being provided with adequate care by a parent, guardian, or relative who has legal custody of the child. Continuing Denial of Periods of Physical Placement or Visitation. As proven by evidence that: • You have been denied periods of physical placement by a court order in an action affecting the family, or have been denied visitation by an order under §§48.345, 48.363, 48.365, 938.345, 938.363, or 938.365, Wis.Stats. • At least one year has elapsed since the order denying periods of physical placement or visitation was issued and the court has not subsequently modified its order so as to permit you periods of physical placement or visitation. Child Abuse. As proven by evidence that: You show a pattern of physically or sexually abusive behavior which is a substantial threat to the health of your child; and that: You have caused death or injury to a child or children resulting in a felony conviction. A child has previously been removed from your home by the court under §48.345, Wis. Stats., after an adjudication that the child is in need of protection or services under § 48.13(3) or (3m). Relinquishment. As proven by evidence that: A court of competent jurisdiction has found pursuant to § 48.13(2m) that you have relinquished custody of your child under § 48.195(1) when the child was 72 hours old or younger. Incestuous Parenthood. As proven by evidence that: You are related, either by blood or adoption, to the child's other parent in a degree of kinship closer than 2nd cousin. Homicide or Solicitation to Commit Homicide of Parent. As proven by evidence that: You have been convicted of the intentional or reckless homicide of the other parent, or solicitation to commit intentional or reckless homicide of the other parent, in violation of §§940.01, 940.02 or 940.05, 939.30, Wis. Stats., or a comparable state or federal law. Parenthood as a Result of Sexual Assault. As proven by evidence that: • You are or may be the father of a child. • The child was conceived as the result of a sexual assault in violation of §§940.225(1),(2) or (3), 948.02(1) or (2), or 948.025 or 948.085, Wis. Stats., which you committed against the child's mother during a possible time of conception. Commission of a Serious Felony Against One of Your Children. As proven by evidence that: You have been convicted of a serious felony as defined in §48.415(9m)(b), Wis. Stats., against one of your children. Prior Involuntary Termination of Parental Rights to Another Child. As proven by evidence that: • Your child has been adjudicated to be in need of protection or services under §48.13(2),(3) or (10), Wis. Stats. or your child was born after a petition for termination of parental rights under §48.415(10), Wis. Stats., was filed in which a sibling of your child is the subject. • In the three years prior to the child being adjudicated in need of protective services as specified in §48.415(10)(a), or in the case of a child born after the filing of a petition regarding a sibling as specified in §48.415(10(a), within three years prior to the date of the birth of the child, a court has ordered the termination of your parental rights with respect to another of your children on one or more grounds specified in §48.415, Wis. Stats. JD-1753 , 04/07 Notice Concerning Grounds To Terminate Parental Rights §§48.356, 48.415 and 938.356, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 Notice Concerning Grounds To Terminate Parental Rights Page 3 of 2 Case No. The court has orally informed me of the applicable grounds for termination of parental rights, and I have received a copy of this notice. Signature of Parent/Expectant Mother Signature of Parent       Date JD-1753 , 04/07 Notice Concerning Grounds To Terminate Parental Rights §§48.356, 48.415 and 938.356, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 2