JV-365 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): TELEPHONE NO.: FOR COURT USE ONLY FAX NO. (Optional): E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: NONMINOR'S NAME: NONMINOR'S DATE OF BIRTH: HEARING DATE AND TIME: DEPT.: CASE NUMBER: TERMINATION OF JUVENILE COURT JURISDICTION—NONMINOR Directions for the social worker or probation officer: Check the appropriate boxes in items 1 through 7, complete item 8, attach documents as required, and sign and date item 9. Directions for the nonminor (if nonminor is available): Review the boxes checked by the social worker or probation officer in items 1 through 7. If the box checked in item 1 is wrong, check the correct box and sign your initials next to the box. Sign your initials on the line after items 2a–h, items 3a–j, item 4, items 5a–b, item 6, and items 7a–h if you received the service or information. Then sign and date item 10. The form may be given to the judge on the day of the hearing if you didn't give it to your social worker, probation officer, or attorney before the hearing. 1. a. b. c. The nonminor wants to attend the termination hearing. The nonminor does not want to attend the termination hearing. The petitioner has attached verification that the nonminor has been informed of the potential consequences of failure to attend the termination hearing. The nonminor is unavailable and/or has refused to sign this form. Evidence of reasonable efforts to locate the nonminor and to obtain his or her signature is attached. 2. An attached report verifies that the nonminor has received written information concerning his or her juvenile court case, including (check all that apply): a. b. c. d. e. f. g. h. Information known about the nonminor's Indian heritage or tribal connections, if applicable ________ The nonminor's family history ________ The nonminor's placement history ________ The nonminor's educational and medical history ________ Any photographs of the nonminor or his or her family in the possession of the county child welfare department or probation department, other than forensic photographs ________ The whereabouts of any siblings under the jurisdiction of the juvenile court except for those siblings for whom the juvenile court has found that sibling contact would jeopardize the safety or welfare of the sibling________ The nonminor's right to go to the clerk’s office and, after demonstrating his or her identity by showing an identification card or by other means, inspect, receive, and copy his or her juvenile case file without an order from the juvenile court (see Welf. & Inst. Code, §§ 826.6 and 827 and rule 5.552 of the California Rules of Court) ________ The date on which the jurisdiction of the court will be terminated ________ 3. The nonminor has been provided with the following documents (check all that apply): Certified birth certificate ________ a. Social security card ________ b. Identification card and/or driver's license ________ c. Proof of citizenship or residency status ________ d. Death certificate of parent or parents, if applicable ________ e. f. Health and Education Passport maintained by the county welfare department or the probation department ________ Form Adopted for Mandatory Use Judicial Council of California JV-365 [Rev. July 1, 2012] TERMINATION OF JUVENILE COURT JURISDICTION—NONMINOR Page 1 of 2 Welfare and Institutions Code, § 391; Cal. Rules of Court, rule 5.555 www.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com JV-365 NONMINOR'S NAME: 3. g. CASE NUMBER: h. An advance health care directive form ________ Letter prepared by the county welfare department that includes the nonminor's name and date of birth, the dates during which he or she was within the jurisdiction of the juvenile court, and a statement that the nonminor was a foster child in compliance with state and federal financial aid documentation requirements ________ i. The nonminor's 90-day Transition Plan ________ j. A blank copy of each of the following: How to Ask to Return to Juvenile Court Jurisdiction and Foster Care (form JV-464-INFO), Request to Return to Juvenile Court Jurisdiction and Foster Care (form JV-466), and Confidential Information—Request to Return to Juvenile Court Jurisdiction and Foster Care (form JV-468) ________ 4. If the nonminor continues to be eligible for services or accommodations under the Individuals With Disabilities Education Act, the Americans With Disabilities Act, or section 504 of the Rehabilitation Act of 1973, he or she has been provided with his or her most recent service or accommodation plan. ________ 5. The nonminor has been receiving services as provided in the Individuals With Disabilities Education Act (34 C.F.R. §§ 300.320(b) and (c), 300.321(b)), and the nonminor has received his or her transition service plan. ________ the nonminor has been informed of the rights that will transfer to him or her under this act. ________ a. b. 6 The nonminor was informed that state agencies, when hiring for internships and student assistant positions, must give preference to qualified applicants up to 26 years of age, who are, or have been, dependent children in foster care. ________ 7. The nonminor received the following: Assistance with an application for Medi-Cal or other health insurance, including information about the availability of a. extended Medi-Cal benefits until age 21 ________ b. Assistance with an application for college, a vocational training program, or other educational or employment program ________ c. Assistance in obtaining financial aid for college, a vocational training program, or other educational or employment program ________ d. e. A referral to transitional housing, if available, or assistance in securing other housing ________ f. g. Assistance in maintaining relationships with individuals important to him or her, consistent with his or her best interest (required only if the nonminor has been in an out-of-home placement for six months or longer) ________ Assistance in accessing the Independent Living Aftercare Program in the nonminor's county of residence ________ h. Other services ordered by the court (specify): Assistance in obtaining employment or other financial support including the CalFresh Program ________ ________ 8. Number of pages attached: 9. I declare under penalty of perjury under the laws of the State of California that the foregoing and all attachments are true and correct. Date:  (TYPE OR PRINT NAME) (SIGNATURE OF SOCIAL WORKER OR PROBATION OFFICER) 10. I certify that I have received the information and services that I initialed above. Date:  (TYPE OR PRINT NAME) JV-365 [Rev. July 1, 2012] (SIGNATURE OF NONMINOR ) TERMINATION OF JUVENILE COURT JURISDICTION—NONMINOR Page 2 of 2