In the interest of




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STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY

For Official Use



IN THE INTEREST OF


     

Name
 Amended


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

1.

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  Foster Parent  Spouse, if any.  If none of preceding, nearest relative.

[Name]      

[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 §§938.13(4), (6), (6m), or (7), Wis. Stats., answer the following:

Juvenile is subject to federal Indian Child Welfare Act? (25 USC §§1901-1963)

 No  Undetermined (Explain:      ______________________________________ )

(For an Indian juvenile who is placed out-of-home, use the Indian Child Welfare Act version [IW-1721] of this petition.)





Name and Address of School Enrolled

     

2. Under section(s)       , the juvenile is

 delinquent

 in need of protection or services, supervision, care or rehabilitation

 in violation of civil law and/or ordinances

because:       See attached

     

 3. The juvenile is placed out-of-home.

a. Placement in the home at this time  is  is not contrary to the welfare of the juvenile and the community.


     

b. Reasonable efforts to prevent removal were [Complete one of the following]



 made by the department or agency responsible for providing services.

     

 made by the department or agency responsible for providing services, although an emergency situation resulted in immediate removal of the child from the home.

     

 not required under §938.355(2d), Wis. Stats.      

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.




Prosecutor




Petitioner



     

Name of Prosecutor Printed or Typed



     

Name of Petitioner Printed or Typed



     

Date


     

Date





JD-1721,05/13 Petition Under Chapter 938- Delinquency, Protection or Services, Civil Law/Ordinances §§938.25 and 938.255, Wisconsin Statutes

This form shall not be modified. It may be supplemented with additional material.

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