For Official Use STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Waiver of Stayed Delinquency Dispositional Order and Order Lifting Stay IN THE INTEREST OF Name Case No. Date of Birth 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 the 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 order. • the condition(s) of the dispositional order I violated were explained to me prior to my violation. • I do not object to the court imposing the condition(s) of the original dispositional order. • I am making this decision of my own free will. 4. 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: Signature of Caseworker Signature of Juvenile Date Date ORDER LIFTING STAY The court has reviewed and approved the above waiver by the juvenile. THE COURT ORDERS: 1. The juvenile shall not be moved from an in home placement to an out of home placement without a hearing. 2. The stay of the condition(s) of the dispositional order is lifted as to: The conditions set forth in paragraph 4 above. That portion of the dispositional order as follows: BY THE COURT: Circuit Court Judge Distribution: 1. Original - Court 2. Caseworker 3. Juvenile Name Printed or Typed Date JD-1750, 08/06 Waiver of Stayed Delinquency Dispositional Order and Order Lifting Stay Wis. Stats. §938.34(16) This form shall not be modified. It may be supplemented with additional material. American LegalNet, Inc. www.FormsWorkflow.com