JIS CODE: COM Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY ORDER OF DISPOSITION, COMMITMENT OR REFERRAL TO DEPARTMENT OF HEALTH AND HUMAN SERVICES (DELINQUENCY PROCEEDINGS), PAGE 1 CASE NO. PETITION NO. Court address Court telephone no. ORI MI- CTN/TCN SID DOB 1. In the matter of name(s), alias(es) 2. Date of hearing: Judge/Referee: Bar no. 3. Notice of hearing for the disposition was given as required by law. 4. The juvenile has appeared in court in person with parent(s), guardian, legal custodian, guardian ad litem, and was represented by an attorney. waived representation by an attorney. 5. An adjudication was held and the court determined that the juvenile committed the following offense(s) and/or the following offense(s) has/have been dismissed: ADJUDICATED BY Count Plea* Court Jury DISMISSED BY* ALLEGATIONS CHARGE CODE(S) MCL Citation/PACC Code *For plea, insert "A" for admission or "NC" for nolo contendere. For dismissal, insert "D" for dismissed by court or "NP" for dismissed by prosecutor/plaintiff. 6. Specific findings of fact and law regarding this proceeding have been made on the record. 7. HIV testing and sex offender registration are completed. 8. A DNA sample is already on file with the Michigan State Police from a previous petition. No assessment is required. 9. The juvenile has been fingerprinted according to MCL 28.243. 10. The offense adjudicated is abstractable to the Secretary of State (under MCL 257.625[20][a], MCL 257.732, MCL 324.80131, MCL 324.81134[12], MCL 324.81135[7], MCL 324.82157, or MCL 333.7408a[12]). The juvenile's driver's license number is . 11. The licensing sanction is reportable to the State Police (under MCL 333.7408a[12] or MCL 257.625[20][b]). Revoked. Suspended days. Restricted days. THE COURT FINDS: 12. It is contrary to the welfare of the juvenile to remain in the home because: 13. a. Reasonable efforts to prevent removal of the juvenile from the home were not made. b. Reasonable efforts were made prior to the placement of the juvenile in foster or other out-of-home care, to prevent or eliminate the need for removing the juvenile from his/her home. Those efforts include: (specify) NOTE: If the juvenile had been previously removed from the home, was then returned to the home, and is being removed again through this order, contrary to the welfare and reasonable efforts findings must be made even though the findings had been made at a prior hearing. Do not write below this line - For court use only (SEE SECOND PAGE) Upon disposition of a juvenile offense as defined under MCL 28.241a(f), the clerk of the court shall advise the Michigan State Police Criminal Justice Information Center of the disposition as required by MCL 712A.18(11). MCL 400.55(h), MCL 712A.18, MCL 712A.18k, MCL 712A.20, MCL 712A.24, MCL 803.301, MCR 3.936, MCR 3.943 JC 25 (6/15) ORDER OF DISPOSITION, COMMITMENT OR REFERRAL TO DEPARTMENT OF HEALTH AND HUMAN SERVICES (DELINQUENCY PROCEEDINGS), PAGE 1 American LegalNet, Inc. www.FormsWorkFlow.com Approved, SCAO JIS CODE: COM STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY ORDER OF DISPOSITION, COMMITMENT OR REFERRAL TO DEPARTMENT OF HEALTH AND HUMAN SERVICES (DELINQUENCY PROCEEDINGS), PAGE 2 CASE NO. PETITION NO. Court address Court telephone no. In the matter of 14. a. Reasonable efforts shall be made to preserve and reunify the family to make it possible for the juvenile to safely return home. b. Reasonable efforts shall not be made to preserve and reunify the family because it would be detrimental to the juvenile's health and safety. c. Reasonable efforts to preserve and reunify the family were not previously required, but due to a change in circumstances, reasonable efforts are now required. Those reasonable efforts have begun and include: (Specify reasonable efforts, and if applicable, the reasons for return.) IT IS ORDERED: 15.The juvenile is placed in the temporary custody of this court. 16. a. The juvenile is committed to the Michigan Department of Health and Human Services under MCL 803.301 (Y.R.A.). b. The juvenile is referred to the Michigan Department of Health and Human Services for placement and care under MCL 400.55(h). c. The juvenile is placed in and shall satisfactorily complete the juvenile boot camp program established by the Michigan Department of Health and Human Services. After satisfactorily completing the program, the juvenile shall be placed in the home of and shall complete a minimum of 120 to a maximum of 180 days of intensive supervised probation in the community. 17. The Director of the Michigan Department of Health and Human Services is appointed special guardian to receive any benefits now due or to become due to the juvenile from the government of the United States. Pending transfer to the Michigan Department of Health and Human Services, temporary placement is as follows: 18. shall participate in treatment programs reasonably available to the parent(s), guardian, or legal custodian. 19. Reimbursement for the cost of care and attorney fees shall be paid as follows: 20. Restitution shall be paid as follows: 21. Other: 22. Juvenile shall pay $ $25.00 for Crime Victim's Rights Fund. State minimum costs specify DNA assessment (not required if item 8. is checked). 23. The review date is Recommended by: Date for each count . . Referee signature Judge Do not write below this line - For court use only JC 25 (6/15) ORDER OF DISPOSITION, COMMITMENT OR REFERRAL TO DEPARTMENT OF HEALTH AND HUMAN SERVICES (DELINQUENCY PROCEEDINGS), PAGE 2 American LegalNet, Inc. www.FormsWorkFlow.com