File No. Name And Address Of Juvenile (check one or more) (Describe immediate threat of harm.) (if applicable) (if applicable) (if applicable) (check one or both) t STATE OF NORTH CAROLINA IN THE MATTER OF Name And Address Of Parent/Guardian/Custodian/CaretakerName And Address Of Parent/Guardian/Custodian/CaretakerJuvenile222s Date Of BirthAgeRaceSexORDER FORNONSECURE CUSTODY(ABUSE/NEGLECT/DEPENDENCY) AOC-J-150, Rev. 1/18 American LegalNet, Inc. www.FormsWorkFlow.com TO ANY LAW ENFORCEMENT OFFICER OR DIRECTOR OF A COUNTY DEPARTMENT OF SOCIAL SERVICES (if blank, the department has no exceptions to the statutory authorization) (designate person, if the Court places the juvenile directly, not through DSS) TO ANY LAW ENFORCEMENT OFFICER (No. 5 on Side One must be checked) Date Of HearingPlace Of HearingTime Of Hearing Signature And Title Of Person Making ReturnName Of Person Who Has Personally Received A Copy Of This Order (type or print)Relationship To JuvenileDepartment Or Agency If the person above gives telephonic approval:Name Of Judge/Judge222s Designee (type or print)Maximum Duration Of Custody Judge Judge222s Designee DateSignature Of Judge/Judge222s Designee Name And Title Of Person Receiving Telephonic ApprovalSignature Of Person Receiving Telephonic ApprovalTime (date) (Add any comments or information about the juvenile222s possible whereabouts.) RETURN ON ORDER Date Order ReceivedDate Order Returned American LegalNet, Inc. www.FormsWorkFlow.com