Fill and Sign the Wisconsin Chapter 48 Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE INTEREST OF       a person under the age of 18. Petition for Protection or Services (Chapter 48)       Date of Birth Case No.       I state on information and belief that the following is true (if unknown or cannot be ascertained, so state): 1. Child’s Street and City Address       Sex       Father’s Name and Address       Father’s Birthdate       Mother’s Name and Address       Mother’s Birthdate       Guardian, Legal Custodian, Spouse, if any. If none, nearest relative’s name and address.       Child in temporary physical custody? No Yes Date/Time:       Where held:       Not disclosed–threat of imminent danger to child-physical custodian. If petition alleges jurisdiction under any basis other than §§938.12, 938.125, 938.13(12), answer the following: Child is subject to federal Indian child welfare act? (25 USC §§1911-1963) No Unascertainable Yes Tribe/address :       Under sections: 2. The child is in need of protection or services because:       See attached.       JC-1610, 10/06 Petition for Protection or Services (Chapter 48) §§48.13 and 48.255, Wisconsin Statutes . This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 Petition for Protection or Services (Chapter 48) Page 2 of 2 Case No. 3. 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:       not possible due to the following emergency situation:       not required under §48.355(2d) because:       4. The person who took this child into custody and the intake worker have made reasonable efforts to return the child home while assuring the child’s health and safety. I request adjudication and entry of an appropriate dispositional order. Signature of District Attorney/Corporation Counsel       Name Printed or Typed       Date Signature of Petitioner       Name Printed or Typed       Date Distribution: 1. Original - Court 2. Child 3. Parent/Guardian/Legal Custodian 4. Department/Agency 5. Other Interested Parties JC-1610, 10/06 Petition for Protection or Services (Chapter 48) §§48.13 and 48.255, Wisconsin Statutes . This form shall not be modified. It may be supplemented with additional material. Page 2 of 2