Approved, SCAO
Original - Court 1st copy - Facility 2nd copy - Facility (for return)
3rd copy - Michigan State Police CJIC 4th copy - Defendant (juvenile) 5th copy - Prosecutor
STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY
ORI
ORDER COMMITTING JUVENILE TO DEPARTMENT OF HUMAN SERVICES
CASE NO.
Court address
Court telephone no.
MI-
Police Report No.
Juvenile's name, address, and telephone no.
THE PEOPLE OF THE STATE OF MICHIGAN
v
CTN/TCN SID DOB
Prosecuting attorney name
Bar no.
Juvenile's attorney name
Bar no.
THE COURT FINDS: 1. The juvenile was found guilty on
CONVICTED BY Count Plea* Court Jury DISMISSED BY* Date
of the crime(s) stated below.
CRIME CHARGE CODE(S) MCL citation/PACC Code
*For plea: insert "G" for guilty plea, "NC" for nolo contendere, or "MI" for guilty but mentally ill. For dismissal, insert "D" for dismissed by court or "NP" for dismissed by prosecutor/plaintiff.
2. The conviction is reportable to the Secretary of State (pursuant to MCL 257.625[20][a], 257.732, 324.80131, 324.81134[12], 324.81135[7], 324.82157, or 333.7408a[11]). The juvenile's driver's license number is: . 3. Licensing sanction reportable to State Police (pursuant to MCL 333.7408a[11] or 257.625[20][b]). Revoked. Suspended days. Restricted days. 4. HIV testing and sex offender registration is completed. Chemical testing for DNA identification profiling is completed. 5. The juvenile has been fingerprinted according to MCL 28.243. IT IS ORDERED: 6. The juvenile is placed on probation and committed to the Department of Human Services pursuant to MCL 803.301 et seq.
(See separate order for probation.)
7. The Director of the Michigan Department of Human Services is appointed special guardian to receive any benefits now due or to become due the juvenile from the government of the United States. 8. Pending transfer to the Department of Human Services temporary custody is as follows: 9. The juvenile is initially placed in the home in a treatment program as follows: with
Name of facility
10. The Department of Human Services shall forward to the court a semiannual progress report on the juvenile (MCL 803.223). 11. The Department of Human Services shall notify the court at least 91 days before the juvenile's 19th birthday of the need to schedule a commitment review hearing (MCL 769.16). 12. The Department of Human Services shall forward to the court a commitment review report for the hearing (MCL 803.225). 13. Reimbursement for the cost of care and service shall be paid as follows: 14. The juvenile shall pay:
State Minimum Crime Victim Restitution Court Costs Attorney Fees Fine Other Costs Total
$60.00 15. Other:
Date
Judge
Bar no. MCL 769.1 et seq., MCL 771.7(2), MCL 775.22, MCL 780.766
CC 236 (3/08)
ORDER COMMITTING JUVENILE TO DEPARTMENT OF HUMAN SERVICES