JD-1762, 02/18 Order for Recoupment of Costs of Legal Services 24724748.275 and 938.275(2), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE INTEREST OF Name Date of Birth Amended Order for Recoupment of Costs of Legal Services Case No. THE COURT FINDS: 1. The child/juvenile has been adjudicated delinquent. adjudicated in violation of a civil law or ordinance. adjudicated in need of protection or services. released with no adjudication. the subject of a request for revision/extension/change of placement/permanency plan review. 2. The State Public Defender Office established that the amount of reimbursement shall be $480 in felony matters and $240 for all other cases. 3. The parents were not the complaining or petitioning party and the interests of the child/juvenile and parents are such that reimbursement would not be unfair. The parents are financially able to reimburse costs. THE COURT ORDERS: 1. The parents shall reimburse the State of Wisconsin for attorney services in the total amount of Felony: $480.00 Other cases: $240.00 Name of Parent 1 : Date of Birth : Address: Name of Parent 2 : Date of Birth : Address: This amount will apply unless the parent meets with the Office of the State Public Defender within 30 days of this O rder to complete a Statement of Income, Assets, and Living Expenses, and is found to be indigent. The State Public Defender shall complete a nd send to the court the Public Defender Response/Order Concerning R ecoupment form for each such parent. Notice to parents: You must have a copy of this O rder available when you contact the State Public Defender Office. 2. The reimbursement shall be paid as follows: jointly by parents (intact household) in the amount of $ per month. as a lump sum. American LegalNet, Inc. www.FormsWorkFlow.com JD-1762, 02/18 Order for Recoupment of Costs of Legal Services 24724748.275 and 938.275(2), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 tot ally by one parent: Parent 1 Parent 2 in the amount of $ per month. as a lump sum. split between the parents (divorced or separa ted household) in the amount of for Parent 1 : $ per month. as a lump sum. for Parent 2 : $ per month. as a lump sum. 3. All payments shall be made to . The first payment shall be due on . Any remaining payment shall be made beginning 30 days after initial payment and each month on that same date until paid in full. 4. Failure by the parents to comply with this order may result in penalties for contempt of court, including incarceration in the county jail for up to 6 months, forfeitures of up to $2,000 per day for each day of noncompliance, and any other order necessary to ensure compliance with this order. THIS IS A FINAL ORDER FOR THE PURPOSE OF APPEAL. DISTRIBUTION: 1. Juvenile Clerk for filing 2. Clerk of Court (for payment record) 3. Parents 4. State Public Defender Office American LegalNet, Inc. www.FormsWorkFlow.com