JD-1767, 02/17 Notice of Postdisposition Emergency Change in Placement and Hearing Request (In-Home to Out-of-Home) 24724748.357(2)(b) and 938.357(2)(b), 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 Notice of Postdisposition Emergency Change in Placement and Hearing Request (In - Home to Out - of - Home) Case No. 1. The child/juvenile is currently under a dispositional order. 2. The placement of the child/juvenile was changed on [Date ] [ Time ] a.m. p.m. due to emergency con dit ions necessitating an immediate change. Give reason for new placement, describe emergency conditions necessitating an immediate change, why it is preferable and how it satisfies any treatment plan ordered by the court: 3. Name and address of new placement: 4. Placement in the home at this time is contrary to the welfare of the child/juvenile because: 5. Reasonable efforts to prevent removal were [Complete one of the following] made by the department or agency responsible for providing services as follows: made by the department or agency responsible for providing services, although an emergency situation resulted in immediate removal of t he child/juvenile from the home as follows: not required under 24748.355(2d) or 247938.355(2d), Wis. Stats., 6. The child/juvenile is subject to the Indian Child Welfare Act, and emergency r emoval and placement outside of the home is is not necessary to prevent imminent physical damage or harm to the chil d/juvenile. 7. It is requested that a hearing in this matter be held no later than [Date] [ Time] a.m. p.m. , which is within 48 hours of the change in placement, excluding Saturdays, Sundays, and legal holidays. 8. The Request for Change in Placement will be fil ed by the time of this hearing. DISTRIBUTION: 1. Court 2. Child/Juvenile 3. Parents/ Guardian/Legal Custodian 4. Case Worker/District Attorney/Corporation Counsel 5. 6. Other: Case Worker/District Attorney/Corporation Counsel Name Printed or Typed Date American LegalNet, Inc. www.FormsWorkFlow.com