IW-1608, 02/18 Temporary Physical Custody Request (Chapter 48) Indian Child Welfare Act Chapter 48, 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 Temporary Physical Custody Request (Chapter 48) Indian Child Welfare Act Referring Agency Case Number Intake Case Number Requesting Agency Complete Name (Last, First, Middle) Date of Birth Place of Birth Tribal Affiliation Chi Telephone Number Fem ale M ale Address If address is on a reservation, which tribe is associated: Why was child taken into custody? (24724748.19, 48.193 or 48.195, Wis. Stats.) Warrant/capias Order by judge Runaway Relinquishment Child suffering from illness, injury or other danger Violation of terms of court - ordered supervision Violation of conditions of temporary custody order Serious health risk to unborn child County of Residence Mother's Name and Address Date of Birth Place of Birth Tribal Affiliation Home T elephone Number Work Telephone Number Father's Name and Address See attached for additional parties . Legal Status: Birth Adjudicated/Adoptive Presum ed Alleged Unknown Date of Birth Place of Birth Tribal Affiliation Home Telephone Number Work T elephone Number Legal Guardian/Indian Custodian's Name and Address Date of Birth Place of Birth Tribal Affiliation Home Telephone Number Wor k Telephone Number Other known information in regard to tribal affiliation or enrollment, including all potential tribes that the child may be a member and aliases or enrollment numbers of parents, grandparents, or other direct lineal ancestors: Date and Time Taken Into Custody Taken Into Custody By Agency The parents notified by referring party? Yes (Date and Time) No Additional information on notice: Why was child not released? Supporting facts of reason why child was taken into physical custody ( 24748.20(3), Wis. Stats.): See attachment (JC - 1609 Temporary Physical Custody Request Supplement) Copy provided to child, if age 12 or over: Yes No Intake Worker Complete Was child (12 years or older) notified of right to counsel? (24748.20(7)(a) or 24748.203(6)(a) , Wis. Stats. ) Yes No Were notice of custody decision and hearing rights provided? (24748.20(8), Wis. Stats.) Mother: Yes, Date Time a.m. p.m. No Father: Yes, Date Time a.m. p.m. No If no, what ongoing effor ts have been made to notify? American LegalNet, Inc. www.FormsWorkFlow.com IW-1608, 02/18 Temporary Physical Custody Request (Chapter 48) Indian Child Welfare Act Chapter 48, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 Indian Custodian: Yes, Date Time a.m. p.m. No If parent(s)/Indian custodian are unknown, what efforts have been made to locate or contact? Tribe: Yes, Date Time a.m. p.m. No Child (12 years or older) : Yes, Date Time a.m. p.m. No Jurisdictional Basis: 1. No Jurisdiction. 2. CHIPS: 247 48.13 , Wis. Stats. Custody Criteria: (24748.205 , Wis. Stats. ) 1. Child will: cause injury to self. be subject to injury by others. run away or be taken away so as to be unavailable for further court proceedings. 2. Parent, guardian, legal custodian or other responsible adult is: neglecting refusing unable unavailable to provide adequate supervision and care. Intake Worker Complete Placement Decision: 1. Child released. 2. Nonsecure custody: (24748.207 , Wis. Stats. ) A . At the home of a parent. relative. guardian. person not a relative. B . At licensed foster home, treatment foster home, or group home. C . At non - secure facility operated by a licensed child welfare agency. D . At licensed private or public shelter care facility (including holdover room). E . At hospital or physician's office if the child is believed to be suffering from a serious physical condition which requires e ither prompt diagnosis or prompt treatment. F . At licensed treatment facility approved by the county as the child is believed to have a mental illness or developmental disability or to be drug dependent and exhibits conduct t hat constitutes a substantial probability of physical harm to the child or to others, or a very substantial probability of physical impairment or injury to the child exists due to the impaire d judgment of the child. G . At approved public treatment facility for emergency treatment as the child is believed to be an i ntoxicated person who has threatened, attempted or inflicted physical harm on himself or herself or on another and is likely to inflict such physical harm unless committed, or is incapacitated by alcohol. H . 3. Secure custody because: (24748.208 , Wis. Stats.) A . A protective order has been issued and the child consents in writing to the placement. B . Child has run away or co mmitted a delinquent act while in nonsecure custody. 4. This is a secure custody placement in a jail because: (24748.209 , Wis. Stats.) A . No other approved juvenile detention facility is available. B . Child is a substantial risk of physical harm to others in a juvenile detention facility. Placement in the home is contrary to the welfare of the child, due to: See attachment (JC - 1609 Temporary Physical Custody Request Supplement) Efforts made to prevent removal and return the child safely to the home include: See attachment (JC - 1609 Temporary Physical Custody Request Supplement) Emergency r emoval and placement outside of the home is necessary to prevent imminent physical damage or harm to the Indian child because: Name of Placement Not disclosed to parent due to imminent danger Address Telephone Number Special precautions/information concerning child/family : Signature of Intake Worker Date and Time Custody Authorized Date and Time of Custody Hearing Date and Time of Release American LegalNet, Inc. www.FormsWorkFlow.com