IW-1610, 11/18 Petition for Protection or Services (Chapter 48) - Indian Child Welfare Act 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) Indian Child Welfare Act Case No. I state on information and belief that the following is true: (if unknown or cannot be ascertained, so state) 1. Name and Address Na me and Address Date of Birth Sex Female Male Race Height Weight Hair Color Eye Color Child has previously been adopted? Yes No Name and Address Date of Birth Name and Address See attached for additional parties . Date of Birth Place of Birth Tribal Affiliation Legal Status: Birth Adjudicated /Adoptive Presum ed Alleged Unknown Other known information in regard to tribal affiliation or enrollment, including all potential tribes that the child/juvenile may be a member and aliases or enrollment numbers of parents, grandparents, or other direct lineal ancestors: Guardian Legal Custodian Indian Custodian Foster Parent Spouse, if any. If none of prec e ding, 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. The child is subject to federal Indian Child Welfare Act (25 USC 2472471901 - 1963). : 3. Under section(s) , the child is in need of protection or services because: See attached 4. The child is placed out of the home. A. Continued custody of the child by the parent or Indian custodian is is not likely to result in serious emotional or physical damage to the child. American LegalNet, Inc. www.FormsWorkFlow.com IW-1610, 11/18 Petition for Protection or Services (Chapter 48) - Indian Child Welfare Act 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. Active efforts were were not made to provide remedial services and rehabilitation programs designed to prevent the breakup of the Indian family. See attached Statement of Active Efforts (IW-1609) C. Placement in the home at this time is is not . D. 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 the child from the home as follows: not required under 24748.35 5(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/Indian Custodian 4. Department/Agency 5. Tribe 6. Other Interested Parties District Attorney/Corporation Counsel/ Petitioner Name Printed or Typed Date American LegalNet, Inc. www.FormsWorkFlow.com