STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit Docket No. In Re: REFERRAL TO APPROVED COMMUNITY JUSTICE PROGRAM Pursuant to 3 3 V.S.A. 247 5232 (b) (7) Based on this court222s finding that the youth named above committed the delinquent act(s) of it is ORDERED that the youth be referred to the following community justice program: The youth shall complete the program no later than . If the community justice program does not accept the youth222s case or if the youth fails to complete the program to the satisfaction of the program, the program shall immediately notify the Court in writing and the youth shall return to Court for disposition. Upon receipt of such notice from the program, the Court will schedule this matter for a disposition. Date Superior Court Judge Acceptance of Referral by Youth I have received this order and understand that I might be asked to pay a fee to participate in the community justice program. I understand that my case will be returned to Court for disposition if 1.I do not contact the community justice program,2.the community justice program does not accept my case, or3.I fail to satisfactorily complete the program.In that case, I understand that I am required to attend a disposition hearing when one is scheduled. Date Signature of Youth Date Signature of Parent/Guardian cc: State222s Attorney Youth222s Attorney GAL (if not present) Community Justice Program DCF (if DCF is a party) 400-00124 226 Referral to Approved Community Justice Program (02/2018) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com TO COMMUNITY JUSTICE PROGRAM: This notice serves as a referral by the Superior Court, Family Division to your community justice program pursuant to 33 V.S.A. 247 5232 (b)(7). The youth has been instructed to contact you within a week of the date of the referral Order. Please use this form to communicate with the Court. Enclosed are a copy of the Referral Order, Petition and Affidavit, and victim impact statement (if one has been filed with the Court). Please note: juvenile matters are CONFIDENTIAL. Unlawful dissemination of information is a crime punishable by a fine up to $2,000. 33 V.S.A. 247 5117 (b)(2). Any records or reports relating to a matter within the jurisdiction of this Court shall not be disseminated by the receiving persons or agencies to any persons or agencies, other than those persons or agencies authorized to receive documents. 33 V.S.A. 247 5117 (e). COMMUNITY JUSTICE PROGRAM NOTICE TO COURT Date: Docket #: Youth222s Name & Date of Birth Most Current Address for Youth In Re: Date of Birth: TO SUPERIOR COURT, FAMILY DIVISION: This is to inform you that the above-named client: failed to contact this Community Justice Program within 7 days of the Court222s referral. was not accepted by the Community Justice Program. failed to complete the Program. successfully compete the Community Justice Program Date Signature of Community Justice Staff Person Printed Name cc: Client/Youth State222s Attorney 400-00124 226 Referral to Approved Community Justice Program (02/2018) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com