Approved, SCAO Original - Court 1st copy - Facility 2nd copy - Facility (for return) 3rd copy - Michigan State Police CJIC 4th copy - Defendant (juvenile) 5th copy - Prosecutor STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY ORI ORDER COMMITTING JUVENILE TO DEPARTMENT OF HEALTH AND HUMAN SERVICES CASE NO. Court address Court telephone no. MI- Police Report No. Juvenile's name, address, and telephone no. THE PEOPLE OF THE STATE OF MICHIGAN v CTN/TCN SID DOB Bar no. Prosecuting attorney name Bar no. Juvenile's attorney name THE COURT FINDS: 1. The juvenile was found guilty on CONVICTED BY Count Plea* Court Jury DISMISSED BY* Date of the crime(s) stated below. CRIME CHARGE CODE(S) MCL citation/PACC Code *Insert "G" for guilty plea, "NC" for nolo contendere, or "MI" for guilty but mentally ill, "D" for dismissed by court or "NP" for dismissed by prosecutor/plaintiff. 2. The conviction is reportable to the Secretary of State (under MCL 257.625[20][a], MCL 257.732, MCL 324.80131, MCL 324.81134[12], MCL 324.81135[7], MCL 324.82157, or MCL 333.7408a[11]). The juvenile's driver's license number is . 3. Licensing sanction reportable to State Police (under MCL 333.7408a[11] or MCL 257.625[20][b]). Revoked. Suspended days. Restricted days. 4. HIV testing and sex offender registration are completed. 5. The juvenile has been fingerprinted according to MCL 28.243. 6. A DNA sample is already on file with the Michigan State Police from a previous petition/case. No assessment is required. IT IS ORDERED: 7. The juvenile is placed on probation and committed to the Department of Health and Human Services pursuant to MCL 803.301 et seq. (See separate order for probation.) 8. The Director of the Michigan Department of Health and Human Services is appointed special guardian to receive any benefits now due or to become due to the juvenile from the government of the United States. 9. Pending transfer to the Department of Health and Human Services, temporary custody is as follows: 10. The juvenile is initially placed in the home in a treatment program as follows: with Name of facility 11. The Department of Health and Human Services shall forward to the court a semiannual progress report on the juvenile (MCL 803.223). 12. The Department of Health and Human Services shall notify the court at least 91 days before the juvenile's 19th birthday of the need to schedule a commitment review hearing (MCL 769.16). 13. The Department of Health and Human Services shall forward to the court a commitment review report for the hearing (MCL 803.225). 14. Reimbursement for the cost of care and service shall be paid as follows: 15. The juvenile shall pay: State Minimum Crime Victim Restitution DNA Assess. Court Costs Attorney Fees Fine Other Costs Total $ 16. Other: $130.00 $ $ $ $ $ $ $ Date Judge Bar no. MCL 769.1 et seq., MCL 771.7(2), MCL 775.22, MCL 780.766 CC 236 (6/15) ORDER COMMITTING JUVENILE TO DEPARTMENT OF HEALTH AND HUMAN SERVICES American LegalNet, Inc. www.FormsWorkFlow.com