JC-1610, 11/18 Petition for Protection or Services (Chapter 48) 24724748.13 and 48.255, 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 a person under the age of 18 Date of Birth Amended Petition for Protection or Services (Chapter 48) Case No. I state on information and belief that the following is true: [if unknown or cannot be ascertained, so state] 1. Street and City Address Date of Birth Sex Female Male Race Height Weight Hair Color Eye Color Child has previously been adopted? Yes No Parent Name and Address See attached for additional parties Parent Legal Status: Birth Adjudicated/Adoptive Presumed Alleged Unknown Parent Name and Address See attached for additional parties Parent Legal Status: Birth Adjudicated/Adoptive Pr esumed Alleged Unknown Guardian Legal Custodian Foster Par ent Spouse, if any. If none of preceding, nearest relative. [Name] [Address] Child in temporary physical custody? No Yes Date Time a.m. p .m . Where held Not disclosed threat of imminent danger to child - physical custodian. 2. Child may be subject to federal Indian Child Welfare Act? (25 USC 2472471901 - 1963) No Undetermined (Explain: ) The Indian child is currently placed in - home; therefore, the federal Indian Child Welfare Act does not apply. For an Indian child who is placed out - of - home, use the Indian Child Welfare Ac t version (IW - 1610) of this P etition. 3. Under section(s) , the child is in need of protection or services because: See attached 4. The child is placed out-of-home. A. Placement in-home at this time is is not contrar. American LegalNet, Inc. www.FormsWorkFlow.com JC-1610, 11/18 Petition for Protection or Services (Chapter 48) 24724748.13 and 48.255, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 B. Reasonable efforts to prevent removal were [Complete one of the following] made by the department or agency responsible for providing services . made by the department or agency responsible for providing services, although an emergency situation resulted in immediate removal of the child from the home . not re quired under 24748.355(2d) , Wis. Stats . 5. The person who took this child into custody and the intake worker have made reasonable efforts to return the child 6. The Uniform Child Custody Jurisdiction Act Affidavit is attached to this Petition. I request adjudication and entry of an appropriate dispositional order. DISTRIBUTION: 1. Court 2. Child 3. Parent/Guardian/Legal Custodian 4. Department/Agency 5. Other Interested Parties District Attorney/Corporation Counsel/ Petitioner Name Printed or Typed Date American LegalNet, Inc. www.FormsWorkFlow.com