IW-1766, 05/18 Request to Change Placement/Revise or Extend or Terminate Dispositional Order/Review Permanency Plan Indian Child Welfare Act 24724748.357, 48.363, 48.365, 48.38, 938.357, 938.363, 938.365 and 938.38, 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 Request to Change Placement Revise Dispositional Order Extend Dispositional Order Review Permanency Plan Terminate Dispositional Order Indian Child Welfare Act Case No. Guardian, Legal/Physical Custodian Address Tribe Address Other Address I am interested as: Child/Juvenile or Counsel Parent Guardian/Legal Custodian/Indian Custodian Case Worker District Attorney/Corporation Counsel Guardian ad Litem Other: I REQUEST THE COURT: (Check all that apply in 1-4) 1. Change the placement of the child/juvenile. a. The child/juvenile is currently under a temporary physical custody order . dispositional order . Give the reason for the new placement, why it is preferable and how it satisfies any treatment plan. See attached c. Name an d address of proposed placement d. Date of proposed change in placement e. The proposed change in placement would change the placement of the child/juvenile from in the home to a placement outside of the home. 1) Continued custody of the child/juvenile by the paren t or Indian custodian is is not likely to result in serious emotional or physical d amage to the child/juvenile. 2) Active efforts were were not made to provide remedial services and rehabilitation programs designed to prevent the brea kup of the Indian family. See attached Statement of Active Efforts (IW - 1609) 3) Placement has been made in accordance with the order of preference set forth in the Indian Child Welfare Act. OR There is good cause to depart from the order of placement preference in the Indian Child Welfare Act. 4) Placement in the home at this time is contrary to the welfare of t he child/juvenile because: American LegalNet, Inc. www.FormsWorkFlow.com IW-1766, 05/18 Request to Change Placement/Revise or Extend or Terminate Dispositional Order/Review Permanency Plan Indian Child Welfare Act 24724748.357, 48.363, 48.365, 48.38, 938.357, 938.363, 938.365 and 938.38, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 5) 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 t he child/juvenile from the home as follows: not required under 24748.355(2d) or 247938.355(2d) , Wis. Stats. 2. Revise the dispositional order. Specify in detail the revisions requested: See attached Because of the following new information: 3. Extend the current dispositional order. Date current dispositional order expires: Date dispositional order should be extended to: Because of the following reasons: See attached 4. Review permanency plan. Permanency plan is attached. is on file with the court. will be provided to the parties five days prior to the hearing. Date of last permanency hearing: Hearing must be held on or before: School name and address: Caseworker name and contact information: 5. Terminate the current dispositional order, which expires on [Date] . Because of the following reasons: See attached DISTRIBUTION: 1. Court 2. Child/Juvenile and Attorney 3. Parents/Attorney (if any) 4. Guardian/Legal Custodian/Indian Custodian 5. Case Worker 6. Physical Custodian 7. District Attorney/Corporation Counsel 8 . Guardian ad Litem 9 . Court Appointed Special Advocate 10. Tribe 11. School (for permanency plan review) 1 2 . Other : Signature Name Printed or Typed Date American LegalNet, Inc. www.FormsWorkFlow.com