Free HOWARD CIRCUIT COURT - Indiana

Approved: 06/19/09 Revised: 06/16/09

D-PDR 10

__________________ COURT JUVENILE DIVISION MODIFICATION REPORT
Date Prepared: Case No: In the Matter of: (a child alleged to be a Delinquent Child) Scheduled Court Date: Report Prepared By: Sources of Information: Reason for Modification Request

JUVENILE'S INFORMATION Family/Living Situation

School Information School of the child's LEGAL SETTLEMENT (Home school district): School currently attending or last attended: Grade: School performance: Employment Information Employed: Yes No Employer: Other employment information: Status: (Select One)

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Approved: 06/19/09 Revised: 06/16/09

D-PDR 10

FINANCIAL INFORMATION Financial Report required by IC 31-37-17-3 and 31-40-1-3 to assist in the determination as to the person's financial responsibility for services provided to the child or the person Mother: TYPE OF INCOME Earned Income Child Support Order payee (list children) Retirement/Pension Social Security/SSI Other unearned income: Father: TYPE OF INCOME Earned Income Child Support Order payee (list children) Retirement/Pension Social Security/SSI Other unearned income: Child: TYPE OF INCOME Earned Income Child Support Order payee (list children) Social Security/SSI Other unearned income: Others in home (including siblings): TYPE OF INCOME Earned Income Child Support Order payee (list children) Social Security/SSI Other unearned income: Child Related Expenses Child care cost Child's share of health insurance Insurance Type Medicaid Private Insurer Amount Paid By AMOUNT (hourly/weekly/monthly) AMOUNT (hourly/weekly/monthly) AMOUNT (hourly/weekly/monthly) AMOUNT (hourly/weekly/monthly)

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Approved: 06/19/09 Revised: 06/16/09

D-PDR 10

Additional Financial Information: Number of children in the home Number of overnights for this child with non-custodial parent: 106 ­ 110 76 ­ 80 0 ­ 51 111 ­ 115 81 ­ 85 52 ­ 55 116 ­ 120 86 ­ 90 56 ­ 60 121 ­ 125 91 ­ 95 61 ­ 65 126 ­ 130 96 ­ 100 66 ­ 70 131 ­ 135 101 ­ 105 71 ­ 75 Additional Information: 136 ­ 140 141 ­ 145 146 ­ 150 151 ­ 155 156 ­ 160 161 ­ 165 166 ­ 170 171 ­ 175 176 ­ 180 181 ­ 183 184+

Additional Financial Information if Recommending Placement OWNER ASSETS CURRENT VALUE (Identify by Name) Checking Account Savings Account Motor Vehicle Life Insurance Other:

STATEMENT OF NEEDS Summary of Risk & Needs Assessments

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Approved: 06/19/09 Revised: 06/16/09 EVALUATION & RECOMMENDATION IV-E Findings Reasonable Efforts/Best Interests (if DCS funded services are being requested)

D-PDR 10

Provide a description of services available before the removal of the child and the efforts made to provide these services:

Provide an explanation why these efforts did not prevent removal of the child:

Explain why these efforts were reasonable:

The safety of the child precludes the immediate use of family services to prevent removal of the child because:

It is in the best interests of the child to be removed from the home environment and remaining in the home would be contrary to the health and welfare of the child because:

Permanency Plan (if youth has been removed from the home or removal is being recommended) Plan (If more than one plan is identified, list plan in order of preference): Reunification Guardianship Another Planned Permanent Living Arrangement Estimated Date for Permanency Plan (one year from date of Preliminary Inquiry): Permanency Plan Court Hearing due date (one year from the date of removal): Adoption Placement with a Fit and Willing Relative

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Approved: 06/19/09 Revised: 06/16/09

D-PDR 10

Evaluation/Summary Compliance with probation services:

Evaluation:

Dispositional Options Considered & Evaluation of Each Option:

Statement of DCS Concurrence/Alternative Recommendation

Probation Recommendation

RECOMMENDED BY: Juvenile Probation Officer

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