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STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE INTEREST OF       Name Petition Under Chapter 938- Delinquency (under age 17) Protection or Services (under age 18) Civil Law/Ordinances (under age 16)       Date of Birth Case No.       I state on information and belief that the following is true (if unknown or cannot be ascertained, so state): Juvenile’s Date of Birth       Sex       Race       Height       Weight       Hair Color       Eye Color       Juvenile’s Street and City Address       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.       Juvenile in temporary custody? No Yes: Date/Time:       Where held:       Not disclosed–threat of imminent danger to juvenile/physical custodian. If petition alleges jurisdiction under any basis other than §§938.12, 938.125, 938.13(12), answer the following: Juvenile is subject to federal Indian child welfare act? (25 USC §§1911-1963) No Unascertainable Yes: Tribe/address:       Name and Address of School Enrolled       Th 2. The juvenile is: delinquent in need of protection or services, supervision, care or rehabilitation under sections in violation of civil law and/or ordinances because: See attached. Under section(s):             JD-1721 , 10/06 Petition Under Chapter 938- Delinquency, Protection or Services, Civil Law/Ordinances §§938.25, 938.255, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 21. Petition Under Chapter 938- Delinquency, Protection or Services, Civil Law/Ordinances Page 2 of 2 Case No. 3. 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:       4. The person who took this juvenile into custody and the intake worker have made reasonable efforts to return the juvenile home while assuring the juvenile’s health and safety. I request adjudication and entry of an appropriate dispositional order. Signature of Prosecutor Signature of Petitioner       Name of Prosecutor Printed or Typed       Name of Petitioner Printed or Typed       Date       Date JD-1721 , 10/06 Petition Under Chapter 938- Delinquency, Protection or Services, Civil Law/Ordinances §§938.25, 938.255, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2