JD-1749, 08/06 Acknowledgement of Dispositional Conditions and Sanctions (Delinquency/JIPS) 247938.3555(6) & (6d), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 1 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE INTEREST OF Name Date of Birth Acknowledgment of Dispositional Conditions and Sanctions (Delinquency/JIPS) Case No. 1. I am the juvenile. The court has imposed a dispositional order in this case. 2. I have read have had read to me the conditions of that dispositional order. 3. I understand the conditions of the order I must obey. 4. I understand that if I violate the order, the court could order one or more of the following sanctions: Place me in a juvenile detention facility or the juvenile portion of a county jail for up to ten days with educational services. (delinquency only) Place me in nonsecure custody for up to ten days with educational services. Suspend or limit the use of my operating privilege (driver's license) or any Department of Natural Resources approval for a period of up to three years. Detain me in my home or current residence for up to 30 days under rules of supervision, including electronic monitoring. Perform up to 25 hours without pay in a supervised work program or other community service. 5. I understand that if my caseworker is investigating whether I violated the order, my caseworker may, without a hearing, place me for up to 72 hours in: A juvenile detention facility. (delinquency only) The juvenile portion of a county jail. (delinquency only) Nonsecure custody. 6. I understand that if I violate the order or my after care status, my caseworker may, without a hearing, place me for up to 72 hours in: A juvenile detention facility. (delinquency only) The juvenile portion of a county jail. (delinquency only) Nonsecure custody. Signature of Caseworker Signature of Juvenile Name Printed or Typed Name Printed or Typed Date Date DISTRIBUTION: 1. Juvenile Clerk 2. Caseworker 3. Juvenile/Juvenile's attorney 4. Juvenile's parents American LegalNet, Inc. www.FormsWorkFlow.com