Approved, SCAO STATE OF MICHIGAN CASE NO. ORDER OF DISPOSITION JUDICIAL CIRCUIT - FAMILY DIVISION PETITION NO. CHILD REMOVED FROM HOME COUNTY (CHILD PROTECTIVE PROCEEDINGS), PAGE 1 Court address Court telephone no.1. In the matter of (name(s), alias(es), DOB) 2. Date of hearing: Judge/Referee: Bar no.3. An adjudication was held and one or more of the statutory grounds allege d in the petition were proven. 4. Notice of hearing for the disposition was given as required by law. 5. The court has considered the case service plan and other evidence presen ted. Specific findings of fact and law regarding this proceeding have been made on the record. THE COURT FINDS: 6. Placement/continuation of the childs residence in the home of is contrary to the welfare of the child(ren) because 7. a. Based on the following findings (attach list if more space is needed) the report dated Identify type of report testimony of backed up by written transcript Name reasonable efforts were were not made prior to the placement of the child(ren) in foster care, to preve nt or eliminate the need for removing the child(ren) from the child(ren)s home and reasonable efforts were were not made to prevent the child(ren)s removal from child(ren)s home or t o rectify the conditions that caused the child(ren)s removal from the c hild(ren)s home in accordance with MCL 712A.18f(4). b. Reasonable efforts to preserve and unify the family are not required bec ause the parent subjected the child(ren) or another child of the parent to abuse including one or more of the types under MC L 712A.19b(3)(k). 8. Parenting time with , even if supervised, may be harmful to the child(ren).NOTE: Contrary to the welfare and reasonable efforts findings only need to be made if the findings had not already been made at a prior hearing and this is the first time the child has been removed fr om the home. (SEE SECOND PAGE) Do not write below this line - For court use only American LegalNet, Inc. www.USCourtForms.com PL 96-272; 42 USC 670 et seq., MCL 400.55(h), MCL 400.203, MCL 712A.13a, MCL 712A.18, MCL 712A.18f, MCL 712A.20, MCR 3.973(F)JC 26 (6/03) ORDER OF DISPOSITION, CHILD REMOVED FROM HOME (CHILD PROTECTIVE PROCEED INGS), PAGE 1 >>>> 2 Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION ORDER OF DISPOSITION CASE NO. CHILD REMOVED FROM HOME PETITION NO. COUNTY (CHILD PROTECTIVE PROCEEDINGS), PAGE 2 Court address Court telephone no.In the matter of IT IS ORDERED: 9. The child(ren) are in the temporary custody of this court and are: a. referred to the Michigan Family Independence Agency for placement and ca re under MCL 400.55(h). It is recommended the child(ren) be placed . b. committed to Michigan Family Independence Agency under MCL 400.203 for o bservation for a period of Maximum 90 days. c. placed in the home of relative .10. The parent, guardian, and/or legal custodian of the child(ren), within 7 days, shall provide the supervising agency with the name and address of the medical provider(s) for the child(ren). 11. In any relative placement, the following apply: a. The parent/guardian/legal custodian shall execute all documents necessar y to release confidential information regarding the child(ren), including medical, mental, and educational reports. Any medical provider of the child(ren) shall release the medical records of the child(ren) to the supervising agency. b. If a home study has not yet been completed, then one shall be performed by the Family Independence Agency and a copy of the home study submitted to the court not more than 30 days afte r the placement. c. Upon request, the Family Independence Agency shall release to the foster parent the information concerning the child(ren) in accordance with MCL 712A.13a(13). 12. The Director of the Michigan Family Independence Agency is appointed spe cial guardian to receive any benefits now due or to become due the child(ren) from the government of the United Stat es. 13. Parent(s) shall comply with the case service plan dated as modified at the hearing. and additionally shall: 14. Parenting time of is as follows: frequent and unsupervised as approved by frequent and supervised by the Family Independence Agency. suspended while psychological evaluation or counseling is conducted and until ordered by the court. 15. Parenting time of is as follows: frequent and unsupervised as approved by frequent and supervised by the Family Independence Agency. suspended while psychological evaluation or counseling is conducted and until ordered by the court. 16.Other: Attach separate sheet. Include reimbursement provisions as required by MCL 712A.18(2) 17. Notice of hearing: Review hearings shall be held as follows: **a foster family agreement or permanent relative placement has been app roved - see MCL 712A.19(4) and 712A.13a(1)(h) 91 day review 182 day review** permanency planning hearing other review Date Judge American LegalNet, Inc. www.USCourtForms.comJC 26 (6/03) ORDER OF DISPOSITION, CHILD REMOVED FROM HOME (CHILD PROTECTIVE PROCEED INGS), PAGE 2