JD-1701, 02/17 Court Referral Child/Juvenile (Law Enforcement Referral) 24724748.24 and 938.24, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. State of Wisconsin, Circuit Court, County 1. Intake Case Number Court Referral Child/Juvenile (Law Enforcement Referral) 2. Court Case Number 3. Child's/Juvenile's Name (Last, First, Middle) 4. Alias/Nickname 5. Age 6. Da te of Birth 7. Sex Female Male 8. Child's/Juvenile's Street Address City State Zip Code 9. County of Residence 10. Race 1. African American 2. Asian or P acific Islander 3. American Indian or Alaskan Native 4. Hispanic 5. Caucas ian 6. Unknown 7. Other 11. Home Telephone 12. School Attended/Place of Employment 13. Grade/Occupation 14. Legal Name and Address Legal Status: Alleged Adjudicated Presumed Biological Unknown Marital Status T E L E P H O N E Work: Home: 15. Legal Name and Address Legal Status: Alleged Adjudicated Presumed Biological Unknown Marital Status Work: Home: 16. Guardian/Legal Custodian/Supervising Agency Address Marital Status Work: Home: 17. Name of Referring Agency 18. Office Telephone 19. File/Case Number 20. Prior Record with Referring Agency: No Yes If yes, describe manner of handling: Additional information attached. 21. Name of Referring Officer 22. Alleged Offenses: Additional information attached. Date(s) Statute Number(s) Offense 23. Name of Accomplic e(s) Address Sex Birt h Date Mo/Day/Yr Referred to Court/Cited F M Yes No F M Yes No F M Yes No 24. Name of Victim and Address 25. Parent(s) Notified: No Yes 26. Date of Referral to Intake Office 27. Property loss or medical bills: No Yes Estimate $ INTAKE INQUIRY RECOMMENDATION 28. Date Received 29. Interview Date and Time: 30. Present at Interview: 31. Custody Authorization: Released Detained Date: Time: a.m. p.m. Nonsecure: Secure: 32. Prior Referrals to Intake: No Yes How Many? If juvenile allege d "Delinquent" under 247938.12, Wis. Stats., attach prior referrals/disposition report to D.A.'s copy. 33. Intake Recommendation - Check all appropriate boxes. A. Case Closed Dismissed - lacks jurisdiction Counseled Referred to Othe r County Other: (Specify) B. Deferred Prosecution/Informal Disposition Agreement Expires: Restitution: $ Supervised Work Program: hrs. Informal Supervision Other: (Specify) C. Formal Petition Requested Ordinanc e Violation - Civil Traffic Offense Delinquency Waiver In Need of Protection/Services under ch. 48 In Need of Protection/Services under ch. 938 34. Comments: 35. Name of Intake Worker/Agency 36. Signature 37. Telephone 38. Date Recommended American LegalNet, Inc. www.FormsWorkFlow.com