SUPERIOR COURT OF WASHINGTON COUNTY OF _______________________ JUVENILE COURT No: STATE OF WASHINGTON v. Order Of Deferred Disposition (ORDFD) Respondent. D.O.B.: Clerk’s Action Required: Paragraphs 4.15, 4.16, 4.17, 4.18 I. Hearing 1.1 Respondent appeared for a disposition hearing pursuant to RCW 13.40.127 on ______________________________ [Date]. The respondent asked the court for deferred disposition at least 14 days prior to the beginning of the trial. The court waived the 14 day requirement for good cause. 1.2 Persons appearing at the hearing were: Respondent Pros. Atty. Prob. Counsl. Resp. Atty. 1.3 Parent Parent Other Testimony was taken. II. Findings 2.1 Count Count Count The court found the respondent guilty of: Offense: Offense: Offense: Committed on or about: Committed on or about: Committed on or about: GV For the offense(s) charged in count(s) __________, domestic violence was pled and proved, RCW 10.99.020 2.2 The respondent meets the requirements of RCW 13.40.127 and qualifies for a deferred disposition. 2.3 The court has consulted with all interested parties. ORD OF DEF DISPOSITION (ORDFD) - Page 1 of 4 WPF JU 07.1320 (06/2012) - RCW 13.40.127 American LegalNet, Inc. www.FormsWorkFlow.com 2.4 The court has considered whether both the juvenile offender and the community will benefit from this deferred disposition. 2.5 The court took into consideration the facts contained in the police report and/or probable cause affidavit and the Statement of Juvenile for Deferred Disposition. The record supports a finding of guilt as to each count, and the court finds the juvenile guilty of each count. III. Restitution 3.1 Restitution is determined to be as follows: Restitution is owed to the victim(s) in the amount of $__________________________. The amount of restitution due the victim(s) cannot be determined at this time and shall be determined no later than: _________________________________ [Date]. Respondent may be ordered to pay restitution pertaining to matters not here adjudicated, and/or Count ________________, notwithstanding dismissal, because respondent, with counsel, so agreed and stipulated. The court is satisfied that the respondent does not have the means to make full or partial payment and could not reasonably acquire the means to pay the amount of restitution due the victims within the term of the deferred disposition. IV. Order It is Hereby Ordered that disposition of Count(s) ________________________________ of the Information be deferred for a period of ______________________________________ months until ______________________________ upon the following conditions (only those paragraphs with boxes checked apply): 4.1 Community Supervision for _______________ months, effective ____________________. A. Respondent shall refrain from committing new offenses. B. Respondent shall comply with the Mandatory School Attendance provisions of RCW 28A.225 and inform respondent’s school of the existence of this requirement. C. Respondent shall perform ______ hours of Community Restitution Work, at a minimum rate of ________ hours per month, to be completed not later than _____________________. The probation counselor may modify this rate in writing. 4.2 Respondent is ordered to Possess No Weapons during this period of community supervision. Probation counselor is authorized to search respondent and items carried or controlled by respondent at scheduled appointments and other reasonable times and may specify in writing further details of this prohibition. 4.3 Counseling and/or information classes, as directed by the supervising probation counselor, including: ________________________________________________ ___________________________________________________________________. 4.4 School/educational/vocational program, as directed by the supervising probation counselor, including: _________________________________________________ ____________________________________________________________________. 4.5 No use and/or possession of alcohol or illegal substances, including random urinalysis at the discretion of the supervising probation counselor. 4.6 Drug/alcohol evaluation and follow-up treatment at the direction of the supervising probation counselor. ORD OF DEF DISPOSITION (ORDFD) - Page 2 of 4 WPF JU 07.1320 (06/2012) - RCW 13.40.127 American LegalNet, Inc. www.FormsWorkFlow.com 4.7 Respondent shall obtain a mental health evaluation and shall comply with treatment recommendations unless otherwise ordered by the court. 4.8 No contact with the following victim(s) _________________________________________ ______________________________________________________________________ _. 4.9 No contact with the co-defendant(s): ______________________________________________________________________. 4.10 Report to and maintain contact with the supervising probation counselor as directed. 4.11 Reside in the home of the respondent’s parent(s) or guardian or at other placement approved by the supervising probation counselor. 4.12 Keep the supervising probation counselor advised of the respondent’s current address and telephone number. 4.13 Commit no further law violations. 4.14 Submit to a curfew of ______________________________, which may be monitored by electronic monitoring at the discretion of the supervising probation counselor. 4.15 Respondent is ordered to pay: Fine of $________________________. Domestic Violence Assessment of $ _________ (up to $100 maximum). Penalty assessment of $________________________. Pursuant to RCW 9.68A.105 or 9A.88.120, fee of $______________ shall not exceed 2/3 of the maximum amount.) Waived. (Waiver Restitution as follows (include name and address): Victim _____________________________________ Amount: $__________________ _____________________________________ Victim _____________________________________ Amount: $__________________ _____________________________________ Victim _____________________________________ Amount: $__________________ _____________________________________ Payable jointly and severally with _____________________________________ _____________________________________________________ at the rate of: $____________________ per month on Count I $____________________ per month on Count II $____________________ per month on Count III Payable at a rate to be determined by the supervising probation counselor. 4.16 DNA Testing. The respondent shall have a biological sample collected for purposes of DNA identification analysis and the respondent shall fully cooperate in the testing. The appropriate agency shall be responsible for obtaining the sample. This paragraph does ORD OF DEF DISPOSITION (ORDFD) - Page 3 of 4 WPF JU 07.1320 (06/2012) - RCW 13.40.127 American LegalNet, Inc. www.FormsWorkFlow.com not apply if it is established that the Washington State Patrol crime laboratory already has a sample from the respondent for a qualifying offense. RCW 43.43.754. Felony Firearm Prohibition: Respondent shall not use or possess a firearm, and under 4.17 federal law any firearm or ammunition, until his or her right to do so is restored by the court in which respondent is adjudicated or the superior court in Washington State where the respondent lives, and by a federal court if required. The court clerk is directed to immediately forward a copy of the respondent’s driver’s license or identicard, or comparable information, along with the date of conviction, to the Department of Licensing. RCW 9.41.047. 4.18 Juvenile Court jurisdiction is extended until: _________________________________. 4.19 Other: _____________________________________________________________________ _____________________________________________________________________. Probation bond of $ _____________________________. 4.20 The Statement of Juvenile for Deferred Disposition was signed by the respondent in open court in the presence of his or her lawyer and the undersigned judge. The respondent asserted that [check appropriate box]: (a) (b) (c) The respondent had previously read the entire statement and that the respondent understood it in full; The respondent’s lawyer had previously read to him or her the entire statement and that the respondent understood it in full; or An interpreter had previously read to the respondent the entire statement and that the defendant understood it in full. INTERPRETER’S DECLARATION: I am a certified or registered interpreter, or have been found otherwise qualified by the court to interpret, in the ____________________________ language, which the respondent understands. I have interpreted this document and the Statement of Juvenile for Deferred Disposition for the respondent from English into that language. I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Signed at (city) ____________________, (state) _________________, on (date) ____________________. _______________________________________ Interpreter ____________________________________________ Print Name Dated: JUDGE/COMMISSIONER ______________________________________ Respondent Presented by: Copy Received; Approved For Entry; Notice of Presentation Waived: Signature Deputy Prosecuting Attorney ORD OF DEF DISPOSITION (ORDFD) - Page 4 of 4 WPF JU 07.1320 (06/2012) - RCW 13.40.127 American LegalNet, Inc. www.FormsWorkFlow.com Print Name WSBA No. Print Name WSBA No. ORD OF DEF DISPOSITION (ORDFD) - Page 5 of 4 WPF JU 07.1320 (06/2012) - RCW 13.40.127 American LegalNet, Inc. www.FormsWorkFlow.com