JV-195 FOR COURT USE ONLY ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number, and address): TELEPHONE NO.: FAX NO.: ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO 2851 MEADOW LARK DR., SAN DIEGO, CA 92123-2792 1701 MISSION AVE., OCEANSIDE, CA 92054 500 THIRD AVE., CHULA VISTA, CA 91910-5694 250 E. MAIN ST., EL CAJON, CA 92020-3913 CHILD'S NAME: WAIVER OF REUNIFICATION SERVICES (Juvenile Dependency) CASE NUMBER: To parent or guardian of child: Read this form carefully. The judge will ask you if you understand your rights and are voluntarily giving up those rights. 1. 2. I am the mother legally presumed father of the child, and I understand that if my child is removed from my custody that I have a right to receive services to help me reunify with my child. I am an alleged biological father of the child, and I understand that if I have been or am judged to be the biological father of the child, the court may order service to help me obtain custody of the child. 3. I am the legal guardian. For items 4 through 9, initial each box that applies unless you have a question. 4. The types of services that may be available have been explained to me. 5. I do not wish to receive services of any kind. 6. I do not wish to reunify with the child or have the child placed in my custody. 7. I understand that if no services are ordered, the court may a. order services to the other parent. b. set the matter for a hearing to decide on the best permanent plan for the child. 8. I understand that if I sign this form and the court is satisfied that I understand my rights and the consequences of giving them up, at the hearing to select a permanent plan for the child, the court may terminate parental rights and have the child placed for adoption. Initial 9. I have discussed my rights with my attorney, and I knowingly and intelligently waive these services. Date: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (SIGNATURE OF PARENT OR GUARDIAN) (TYPE OR PRINT NAME) Declaration of Interpreter 10. The parent or guardian is unable to read or understand this form of waiver because his or her primary language is Spanish other (specify): 11. I declare under penalty of perjury under the laws of the State of California that I have, to the best of my ability, read or translated this form of waiver to the parent or guardian. The parent or guardian said he or she understood the form before signing it. Date: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (TYPE OR PRINT NAME) (SIGNATURE OF INTERPRETER) Declaration of Attorney (Required) 12. I am the attorney for the parent or guardian. I have explained to the parent or guardian the nature of reunification services, including the statutory time limits for such services. I have advised the parent or guardian of the parent's or guardian's right to such services and the potential consequences of waiving them, including the likelihood that parental rights will be terminated and the child placed for adoption. I am satisfied that the parent or guardian understands these rights and is voluntarily waiving them. Date: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (TYPE OR PRINT NAME) Form Adopted by the Judicial Council of California JV-195 [New July 1, 1998] SUPCT JUV-140 (New 7-98) (SIGNATURE OF ATTORNEY) WAIVER OF REUNIFICATION SERVICES (Juvenile Dependency) Welfare & Institutions Code, § 361.5 2000 (C) American LegalNet, Inc.