IW-1721, 11/18 Petition for Protection or Services (Chapter 938) Indian Child Welfare Act 247247938.25, and 938.255, 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 Name Date of Birth Amended Petition for Protection or Services (Chapter 938) 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 Name and Address Date of Birth Sex Female Male Race Height Weight Hair Color Eye Color Juvenile has previously been adopted? Yes No Name and Address Date of Birth Place of Birth Tribal Affiliation Name and Address See attached for additional parties of Birth of Birth Legal Status: Alleged Adjudicated Presumed Biological Unknown Other known information in regard to tribal affiliation or enrollment, including all potential tribes that the juvenile may be a member and aliases or enrollment numbers of parents, grandparents, or other direct lineal ancestors: Guardian Legal Custodian Indian Cus todian Foster Parent Spouse, if any. If none of preceding, nearest relative. [Name] [Address] Juvenile in temporary custody? No Yes Date Time a.m. p.m. Where held Not disclosed threat of imminent danger to juvenile/physical custodian. 2. The petition alleges jurisdiction under 247247938.13(4 ), (6), (6m), or (7), Wis. Stats., and the juvenile is subject to fed eral Indian Child Welfare Act (25 U . S . C . 2472471901 - 1963). Name and Address of School Enrolled 3. Under section(s) , the juvenile is in need of protection or services because: See attached American LegalNet, Inc. www.FormsWorkFlow.com IW-1721, 11/18 Petition for Protection or Services (Chapter 938) Indian Child Welfare Act 247247938.25, and 938.255, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 4. The juvenile is placed out of the home. A. Continued custody of the juvenile by the parent or Indian custodian is is not likely to result in serious emotional or physical damage to the juvenile. 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 contrary to the welfare of the juvenile and the community. 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 immedia te removal of the juvenile from the home as follows: not required under 247938.355(2d) , Wis. Sta ts . 5. The person who took this juvenile into custody and the intake worker have made reasonable efforts to return the I request adjudication and entry of an appropriate dispositional order. DISTRIBUTION: 1. Court 2. Juvenile 3. Parent/Guardian/Legal C ustodian/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