THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Number: IN THE MATTER OF: IN THE MATTER OF: IN THE MATTER OF: IN THE MATTER OF: DOB: DOB: DOB: DOB: THE EFFECT OF A CONSENT ORDER WITHOUT A FINDING The Court's approval of a consent order without a finding in the matter alleging that your child(ren) has(have) been abused and/or neglected affects your constitutionally protected rights, including your parental rights, as follows: 1. You acknowledge and understand that as a result of the consent decree, legal supervision will be awarded to the Division for Children, Youth and Families (DCYF), and that your child(ren) will be permitted to remain in her/his home under the supervision of DCYF subject to further court order. 2. You acknowledge and understand that the Court may order the Division for Children, Youth and Families (DCYF) to complete a social study. You further acknowledge that the Court may conduct a dispositional hearing and may issue dispositional orders, pursuant to RSA 169-C:19, and that you will be required to comply with these orders. In addition to the dispositional hearing, you acknowledge and understand that the Court may conduct periodic review hearings to review the status of this matter and your compliance to date with the Court's orders. You further acknowledge that the Court may conduct a final review hearing to determine when this matter should be closed. 3. You acknowledge and understand that if you do not comply with any of the Court's orders, or any additional orders included in the consent decree, any party may file a motion with the Court for a contempt hearing or the Court may, on its own, schedule a contempt hearing. If you are found in contempt by the Court, sanctions may be imposed. 4. You acknowledge and understand that if there are new allegations of abuse or neglect against you, DCYF may file another petition with the Court. You further acknowledge and understand that as a result of this new petition, legal custody may be awarded to DCYF and that DCYF would have the right to temporarily remove your child from your parental care and custody and determine where and with whom your child(ren) will live, including, but not limited to, placing your child(ren) in a foster home(s). NHJB-2258-DF (01/01/2011) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Number: EFFECT OF CONSENT ORDER WITHOUT A FINDING By signing below, you acknowledge that you are informed of the consequences of the consent order. You further represent by signing below that you voluntarily and intelligently consent to the terms and conditions of the consent order dated , which is hereby incorporated. Date Signature of Parent Printed Name of Parent Signature of Parent's Attorney (if applicable) Printed Name of Parent's Attorney (if applicable) I have reviewed the content of this form and the consent order dated with the above-named and have informed her/him of the consequences of the consent order. I have also determined that the above-named has voluntarily and intelligently consented to the terms and conditions of the consent order dated , which is hereby incorporated. Recommended: Date Signature of Marital Master Printed Name of Marital Master So Ordered: I hereby certify that I have read the recommendation(s) and agree that, to the extent the marital master/judicial referee/hearing officer has made factual findings, she/he has applied the correct legal standard to the facts determined by the marital master/judicial referee/hearing officer. Date Signature of Judge Printed Name of Judge NHJB-2258-DF (01/01/2011) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com