State of Indiana s4

Approved: 8.08 D-14.02

Revised:

STATE OF INDIANA

________________________________ COURT

In The Matter Of _________________________

________________________________________ Case No. _________

A Delinquent Child

VERIFIED PETITION FOR MODIFICATION OF DISPOSITIONAL DECREE

Your petitioner alleges and says:

1. The capacity in which your petitioner files this petition is:

__________________________________________________________________

[here set forth capacity of petitioner as required by IC 31-37-22-1]

2. That on the _____ day of _________________, 20___, the Court entered a dispositional decree in this cause wherein __________________________________________________________________

__________________________________________________________________

[here set forth particulars of dispositional decree]

3. Your petitioner further alleges and says: __________________________________________________________________

__________________________________________________________________

[here set forth details of probation violation or other facts justifying modification]

4. The current legal settlement of the child is _____________________________.

5. Your petitioner believes that the following modification is necessary and appropriate:

_________________________________________________________________

__________________________________________________________________

[here set forth particulars of requested change or additional information].

6. Referral (has) (has not) been made to the local coordinating committee. (If applicable)

7. That a modification report is filed.

8. Your petitioner (does) (does not) request an emergency change in the child’s residence for the following reasons: __________________________________________________________________

__________________________________________________________________

9. The following temporary change in placement order is requested:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

10. [ ] The modification requested does not affect any placement, program or services for or on behalf of the child payable by DCS.

[ ] DCS has received a copy of the modification report and its concurrence is attached as Exhibit ___).

[ ] DCS does not concur with the modification proposal and has submitted an alternate proposal which is attached as Exhibit ___for the court’s consideration.

WHEREFORE the petitioner requests the following relief:

1. to schedule a hearing for this petition ;

2. that notice be given to all affected persons, including said child, his parent, guardian or custodian;

3. the modification of said dispositional decree as requested herein; and

4. for all further and proper relief, including the issuance of a temporary order, if an emergency has been alleged herein.

5. If the court issues a temporary order for emergency change in the child’s residence, to schedule a hearing on the temporary order if requested by any of the persons affected.

I affirm under the penalties of perjury that the foregoing representations and statements are true.

Dated: ___________________

______________________________________

Petitioner