Free JV-195 WAIVER OF REUNIFICATION SERVICES (Juvenile Dependency) - California

COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number, and address): : :
TELEPHONE NO.: ATTORNEY FOR (Name): FAX NO.:

JV-195

Index No. Calendar No.

FOR COURT USE ONLY

Plaintiff(s)

: : : :

JUDICIAL SUBPOENA

-against-

SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME:

CHILD'S NAME:

Defendant(s) : ......................................................
WAIVER OF REUNIFICATION SERVICES
(Juvenile Dependency)
CASE NUMBER:

To parent or guardian of child: Read this form carefully. The judge will ask you if you understand your rights and are voluntarily THE PEOPLE OF giving up those rights. THE STATE OF NEW YORK 1. 2. I am TO the mother legally presumed father of the child, and I understand that if my child is removed from my custody that I have a right to receive services to help me reunify with my child. I am an alleged biological father of the child, and I understand that if I have been or am judged to be the biological father of the child, the court may order service to help me obtain custody of the child.

3. I am the legal guardian. GREETINGS: For items 4 through 9, initial each box that applies unless you have a question. Initial 4. The types of services that may be available have been explained to me. WE COMMAND any kind. 5. I do not wish to receive services of YOU, that all business and excuses being laid aside, you and each of you attend before the wish to reunify with the child or have the child placed at the custody. Honorable Court in my 6. I do not located at County of if no services are ordered, the court may 7. I understand that in room , on parent. day of , 20 , at o'clock in the noon, and at any recessed a. order services to the otherthe b. set adjournedfor a hearing to decide on the best permanent plan for the child. on the part of the or the matter date, to testify and give evidence as a witness in this action 8. I understand that if I sign this form and the court is satisfied that I understand my rights and the consequences of giving them up, at the hearing to select a permanent plan for the child, the court may terminate parental rights and have the child placed for adoption.

,

Your rights with my attorney, and I subpoena is intelligently waive these services. 9. I have discussed my failure to comply with this knowingly andpunishable as a contempt of court and will make you liable to Date: the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.
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(TYPE OR PRINT NAME) Witness, Honorable Court in County, (SIGNATURE OF PARENT OR GUARDIAN)

, one of the Justices of the

Declaration of Interpreter day of , 20

10. The parent or guardian is unable to read or understand this form of waiver because his or her primary language is Spanish other (specify): 11. I declare under penalty of perjury under the laws of the State of California that I have, to the best ofand type name below)translated this (Attorney must sign above my ability, read or form of waiver to the parent or guardian. The parent or guardian said he or she understood the form before signing it. Date:

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(TYPE OR PRINT NAME)

Attorney(s) for
(SIGNATURE OF INTERPRETER)

Declaration of Attorney (Required)
12. I am the attorney for the parent or guardian. I have explained to the parent or guardian the nature of reunification services, including Office the P.O. Address the statutory time limits for such services. I have advised the parent or guardian of andparent's or guardian's right to such services and the potential consequences of waiving them, including the likelihood that parental rights will be terminated and the child placed for adoption. I am satisfied that the parent or guardian understands these rights and is voluntarily waiving them. Date:

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(TYPE OR PRINT NAME) Form Adopted by the Judicial Council of California JV-195 [New July 1, 1998]

WAIVER OF REUNIFICATION SERVICES
(Juvenile Dependency)

Telephone No.: Facsimile No.: E-Mail Address: (SIGNATURE OF ATTORNEY) Mobile Tel. No.: Welfare & Institutions Code, § 361.5
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