THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) JUVENILE DIVERSION AGREEMENT In the matter of A petition has been filed by Charging the juvenile with Contrary to RSA 169and RSA The juvenile and (check one of the following) parents guardian other custodian have been advised that the court will not appoint an attorney or Guardian ad Litem during this voluntary process and that the juvenile may decline to participate in this process and instead, elect to proceed to a hearing before a judge. The parties whose signatures appear below have been informed of the following: A. Within days, the Juvenile Probation and Parole Officer of Assessment and Diversion will notify the court that the terms of this agreement have or have not been completed to the Juvenile Probation and Parole Officer's satisfaction. B. Upon notification to the court of the satisfactory completion of the terms of this agreement, the court will mark the case "WITHDRAWN". C. Upon notification to the court of the unsuccessful compliance with this agreement, the petition will be served and the matter scheduled for arraignment. D. The following are the conditions of this agreement which must be satisfied for the case to be withdrawn: NHJB-2354-DF (01/01/2012) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: JUVENILE DIVERSION AGREEMENT This Juvenile Diversion Agreement is dated Petitioner Signature Petitioner Address Juvenile Signature Juvenile Address Parent/Guardian Signature Parent/Guardian Address Parent/Guardian Signature Parent/Guardian Address Other Signature Other Address Juvenile Probation and Parole Officer Signature ________________________________________________________________________________________________ The juvenile and (check one of the following) parents guardian given knowing, informed and voluntary consent to this diversion referral. This Juvenile Diversion Agreement is approved. Date Signature of Judge other custodian have Printed Name of Judge COMPLETION REPORT (To be submitted to the court at the conclusion of this agreement) The undersigned Juvenile Probation and Parole Officer of Assessment and Diversion certifies to the court that: Diversion was successfully completed CASE SHOULD BE WITHDRAWN Diversion was unsuccessful. PETITION SHOULD BE SERVED. Date Juvenile Probation and Parole Officer for Assessment and Diversion NHJB-2354-DF (01/01/2012) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com