POLICE REFERRAL SUMMARY JD-JM-57 Rev. 10-10 C.G.S. § 46b-137 Pr. Bk. Sec. 27-5 Name of juvenile Address of juvenile (Number, street and town) Name of school STATE OF CONNECTICUT SUPERIOR COURT JUVENILE MATTERS Sex Race Date of birth Date of referral Father's name Date of birth Father Address Telephone number Employer Mother's name Date of birth Mother Address Telephone number Employer Summary of delinquent acts alleged (Each act to be listed separately) General Statute number and title Date and place of delinquent act Name and address of victim 1 2 3 4 A copy of the police department's Official Investigation (Serial) is to be attached to this form and must accompany the juvenile being delivered to a juvenile detention center. Police Officer Badge number Town Refer to Connecticut General Statute section 46b-137 and Connecticut Practice book section 27-5 when taking statements from juveniles. "X" here if more space is needed and continue on the back of this form. American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 1