JD-1766, 05/19 Request to Change Placement/Revise Dispositional Order/Extend Dispositional Order/Review Permanency Plan/Terminate Consent Decree/Dispositional Order 24724748.32, 48.357, 48.363, 48.365, 48.38, 938.32, 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 Consent Decree / Dispositional Order Case No. Street and City Address Parent 1 Name Parent 1 Parent 2 Name Parent 2 Guardian, Legal/Physical Custodian Address Other Address I REQUEST THE COURT : ( C heck all that apply in 1 - 6 ) 1. I am interested as Child/Juvenile or Counsel Parent Ca se Worker District Attorney/Corporation Counsel Guardian ad Litem Expectant Mother Other: 2. The provisions of the Indian Child Welfare Act do not apply. (For an Indian child who is placed out - of - home, use the Indian Child Welfare Act version (IW - 1766) of this form.) 3. Change the placement of the child/juvenile. A. The child/juvenile is currently under a temporary physical custody order. dispositional order. B. 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 move the child/juvenile from in the home to a placement outside of the home. 1) Placement in the home at this time is contrary to the welfare of the child/juvenile because: 2) Reasonable efforts to prevent removal were ( Complete one of the following ) made by the department or agency re sponsible for providing services as follows : American LegalNet, Inc. www.FormsWorkFlow.com JD-1766, 05/19 Request to Change Placement/Revise Dispositional Order/Extend Dispositional Order/Review Permanency Plan/Terminate Consent Decree/Dispositional Order 24724748.32, 48.357, 48.363, 48.365, 48.38, 938.32, 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 made by the department or agency responsible for providing services, although an emergency situation resulted in immediate removal of the child/juvenile from the home as follows: not required under 24748. 355(2d) or 247938.355(2d) , Wis. Stats . , 4. Revise the dispositional order. Specify in detail the revisions requested: See attached Because of the following ne w information: See attached 5. Extend the current dispositional order. Date current dispositional order expires: Date dispositional order should be extended to: Because of the following reasons: See attached 6. 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: 7. Terminate the current consent decree or dispositional order, which expires on [Date] . Because of the following reasons: See attached DISTRIBUTION: 1. Court 2. Child/Juvenile and Attorney 3. Parents/Guardian/Legal Custodian/Attorney (if any) 4. Case Worker 5. Physical Custodian 6. District Attorney/Corporation Counsel 7. Guardian ad Litem 8 . Court Appointed Special Advocate 9. School (for permanency plan review) 10 . Other : Signature Name Printed or Typed Date American LegalNet, Inc. www.FormsWorkFlow.com