JD-1750A, 08/06 Request for Imposition of Stayed Delinquency Dispositional Order 247938.34(16), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE INTEREST OF Name Date of Birth Request for Imposition of Stayed Delinquency Dispositional Order Case No. 1. I am the juvenile found delinquent in this case. The court has imposed and stayed: the entire dispositional order. a portion of the dispositional order. 2. The case worker and I agree that imposing th e stayed conditions will not move me from an in - home to an out - of - home placement. 3. I agree that a hearing is not necessary because I admit I violated the disposition al order. the condition(s) of the dispositional order I violated was/ were expla ined to me prior to my violation. 4. I do not object to the court imposing the condition(s) of the original dispositional order. 5. I am making this decision of my own free will. 6 . Although I understand that the court is not bound by this request and may impose the entire terms of the dispositional order, the caseworker and I are requesting the following conditions be imposed: Caseworker Juvenile Name Printed or Typed Name Printed or Typed Date Date DISTRIBUTION: 1. Court 2. Caseworker 3. Juvenile American LegalNet, Inc. www.FormsWorkFlow.com