Approved, SCAO JIS CODE: DSP STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY ORDER OF DISPOSITION, IN-HOME (DELINQUENCY PROCEEDINGS) 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 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. The court determined that the juvenile committed the following offense(s) and/or the following offense(s) has/have been dismissed: ADJUDICATED BY DISMISSED BY* Count Plea* Court Jury CHARGE CODE(S) MCL Citation/PACC Code ALLEGATIONS *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, 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. IT IS ORDERED: 12. is warned and the petition is dismissed.* Name (type or print) 13. The juvenile is placed on 14. Other: specify type probation in the home of . (Include reimbursement as required by MCL 712A.18[2] or as permitted by MCL 769.1f.) 15. Juvenile shall pay $ $25.00 for Crime Victim's Rights Fund. State minimum costs specify for each count DNA assessment (not required if item 8. is checked). 16. The review date is 17. The petition is dismissed.* Recommended by: . . Referee signature Judge Date *Note: Check 12 only if all or some of the material allegations are sustained. Check 17 only if all of the material allegations are not sustained. Do not write below this line - For court use only Upon disposition of a juvenile offense as defined pursuant to 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). JC 14a (6/15) MCL 28.241a, MCL 600.2950h, MCL 600.2950m, MCL 712A.18, MCL 712A.18k, MCL 712A.20, MCL 764.15b, MCL 769.1f, MCL 769.16a, MCR 3.936, MCR 3.943 ORDER OF DISPOSITION, IN-HOME (DELINQUENCY PROCEEDINGS) American LegalNet, Inc. www.FormsWorkFlow.com