Form JV-421 "Dispositional Attachment - Removal From Custodial Parent - Placement With Nonparent" - California

What Is Form JV-421?

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  • Released on January 1, 2018;
  • The latest edition provided by the California Judicial Branch;
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Download Form JV-421 "Dispositional Attachment - Removal From Custodial Parent - Placement With Nonparent" - California

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JV-421
CHILD'S NAME:
CASE NUMBER:
DISPOSITIONAL ATTACHMENT:
REMOVAL FROM CUSTODIAL PARENT
PLACEMENT WITH NONPARENT
(Welf. & Inst. Code, §§ 361, 361.2)
1.
The child is a person described by Welf. & Inst. Code, § 300 (check all that apply):
300(a)
300(c)
300(e)
300(g)
300(i)
300(b)
300(d)
300(f)
300(h)
300(j)
and is adjudged a dependent of the court.
Circumstances justifying removal from custodial parent
There is clear and convincing evidence of the circumstances stated in Welf. & Inst. Code, § 361 regarding the persons
2.
specified below (check all that apply):
361(c)(1)
361(c)(2)
361(c)(3)
361(c)(4)
361(c)(5)
a.
Mother
b.
Presumed father
c.
Biological father
d.
Legal guardian
e.
Indian custodian
f.
Other
(specify):
3.
The child
is
may be
an Indian child, and, by clear and convincing evidence, including testimony of a
qualified expert witness, continued physical custody by the following person is likely to cause the child serious emotional or
physical damage:
mother
biological father
legal guardian
presumed father
Indian custodian
other
(specify):
4. Reasonable efforts
made to prevent or eliminate the need for removal from the home.
were
were not
5.
The child
is
may be
an Indian child, and,
a.
by clear and convincing evidence, active efforts were made to provide remedial services and rehabilitative programs
designed to prevent the breakup of this Indian family, and these efforts were unsuccessful.
b.
active efforts were not made to provide remedial services and rehabilitative programs designed to prevent the breakup of
this Indian family.
c.
there has been consultation with the child's identified Indian tribe regarding whether tribal customary adoption is an
appropriate permanent plan for the child if reunification is unsuccessful.
6.
Based on the facts stated on the record, continuance in the home is contrary to the child's welfare and physical custody is
removed from (check all that apply):
mother
biological father
legal guardian
presumed father
Indian custodian
other
(specify):
Family finding and engagement
7. a.
The county agency has exercised due diligence to identify, locate, and contact the child's relatives.
b.
The county agency has not exercised due diligence to identify, locate, and contact the child's relatives.
(1)
The county agency is ordered to make such diligent efforts, except for individuals the agency has determined to be
inappropriate to contact because of their involvement with the family or domestic violence.
The county agency must submit a report to the court on or before (date):
(2)
detailing the diligent efforts made and the results of such efforts.
Page 1 of 7
Form Approved for Optional Use
DISPOSITIONAL ATTACHMENT: REMOVAL FROM
42 United States Code § 675;
Judicial Council of California
Welfare and Institutions Code, §§ 361, 361.2, 361.5, 16501.1;
CUSTODIAL PARENT
PLACEMENT WITH
JV-421 [Rev. January 1, 2018]
Cal. Rules of Court, rules 5.690, 5.695
www.courts.ca.gov
NONPARENT
(Welf. & Inst. Code, §§ 361, 361.2)
JV-421
CHILD'S NAME:
CASE NUMBER:
DISPOSITIONAL ATTACHMENT:
REMOVAL FROM CUSTODIAL PARENT
PLACEMENT WITH NONPARENT
(Welf. & Inst. Code, §§ 361, 361.2)
1.
The child is a person described by Welf. & Inst. Code, § 300 (check all that apply):
300(a)
300(c)
300(e)
300(g)
300(i)
300(b)
300(d)
300(f)
300(h)
300(j)
and is adjudged a dependent of the court.
Circumstances justifying removal from custodial parent
There is clear and convincing evidence of the circumstances stated in Welf. & Inst. Code, § 361 regarding the persons
2.
specified below (check all that apply):
361(c)(1)
361(c)(2)
361(c)(3)
361(c)(4)
361(c)(5)
a.
Mother
b.
Presumed father
c.
Biological father
d.
Legal guardian
e.
Indian custodian
f.
Other
(specify):
3.
The child
is
may be
an Indian child, and, by clear and convincing evidence, including testimony of a
qualified expert witness, continued physical custody by the following person is likely to cause the child serious emotional or
physical damage:
mother
biological father
legal guardian
presumed father
Indian custodian
other
(specify):
4. Reasonable efforts
made to prevent or eliminate the need for removal from the home.
were
were not
5.
The child
is
may be
an Indian child, and,
a.
by clear and convincing evidence, active efforts were made to provide remedial services and rehabilitative programs
designed to prevent the breakup of this Indian family, and these efforts were unsuccessful.
b.
active efforts were not made to provide remedial services and rehabilitative programs designed to prevent the breakup of
this Indian family.
c.
there has been consultation with the child's identified Indian tribe regarding whether tribal customary adoption is an
appropriate permanent plan for the child if reunification is unsuccessful.
6.
Based on the facts stated on the record, continuance in the home is contrary to the child's welfare and physical custody is
removed from (check all that apply):
mother
biological father
legal guardian
presumed father
Indian custodian
other
(specify):
Family finding and engagement
7. a.
The county agency has exercised due diligence to identify, locate, and contact the child's relatives.
b.
The county agency has not exercised due diligence to identify, locate, and contact the child's relatives.
(1)
The county agency is ordered to make such diligent efforts, except for individuals the agency has determined to be
inappropriate to contact because of their involvement with the family or domestic violence.
The county agency must submit a report to the court on or before (date):
(2)
detailing the diligent efforts made and the results of such efforts.
Page 1 of 7
Form Approved for Optional Use
DISPOSITIONAL ATTACHMENT: REMOVAL FROM
42 United States Code § 675;
Judicial Council of California
Welfare and Institutions Code, §§ 361, 361.2, 361.5, 16501.1;
CUSTODIAL PARENT
PLACEMENT WITH
JV-421 [Rev. January 1, 2018]
Cal. Rules of Court, rules 5.690, 5.695
www.courts.ca.gov
NONPARENT
(Welf. & Inst. Code, §§ 361, 361.2)
JV-421
CHILD'S NAME:
CASE NUMBER:
Case plan development
8. a.
The county agency solicited and integrated into the case plan the input of the
child
father
mother
representative of child's identified Indian tribe
other
(specify):
b.
The county agency did not solicit and integrate into the case plan the input of the
child
mother
father
representative of child's identified Indian tribe
other
(specify):
and the agency is ordered to do so and submit an updated case plan within 30 days of the date of this hearing.
c.
The county agency did not solicit and integrate into the case plan the input of the
child
mother
representative of child's identified Indian tribe
other
father
(specify):
and the county agency is not required to do so because these persons are unable, unavailable, or unwilling to participate.
Custody and placement
The
did not reside with the child at the time the petition
9.
mother
presumed father
biological father
was filed and
desire custody of the child.
does
does not
a.
By clear and convincing evidence, placement with the following parent would be detrimental to the safety, protection, or
physical or emotional well-being of the child:
Mother
Presumed father
Biological father
b.
The factual basis for the findings in this item is stated on the record.
10.
The care, custody, control, and conduct of the child is under the supervision of the county agency for placement
a.
in the approved home of a relative.
b.
in the approved home of a nonrelative extended family member.
c.
in the foster home in which the child was placed before an interruption in foster care because that placement is in the
child's best interest and space is available.
d.
with a foster family agency for placement in a foster family home.
e.
in a suitable licensed community care facility.
f.
in a home or facility in accordance with the federal Indian Child Welfare Act.
Placement with the child's relative, (name):
11.
has been independently considered by the court and is denied for the reasons stated on the record.
The statutory preference order for placement in a suitable Indian home is modified for good cause as
12.
a.
stated on the record.
b.
described in the social worker's report.
other
(specify):
c.
The child's out-of-home placement is necessary.
13.
The child's current placement is appropriate.
14.
The child's current placement is not appropriate. The county agency must locate an appropriate placement for the child.
15.
a.
The matter is continued to the date and time indicated in form JV-415, item 17 for a
written
oral
report by the county agency on the progress made in locating an appropriate placement.
Other
(specify):
b.
The child is placed outside the state of California and that out-of-state placement
16.
a.
continues to be the most appropriate placement for the child and is in the best interest of the child.
b.
is not the most appropriate placement for the child and is not in the best interest of the child.
written
oral
The matter is continued to the date and time indicated in form JV-415, item 17 for a
report by the county agency on the progress made toward
(1)
returning the child to California and locating an appropriate placement within California.
(2)
locating an out-of-state placement that is the most appropriate placement for the child and in the best interest of the
child.
other
(specify):
(3)
DISPOSITIONAL ATTACHMENT: REMOVAL FROM
JV-421 [Rev. January 1, 2018]
Page 2 of 7
CUSTODIAL PARENT
PLACEMENT WITH
NONPARENT
(Welf. & Inst. Code, §§ 361, 361.2)
JV-421
CHILD'S NAME:
CASE NUMBER:
Reunification services
17.
Provision of reunification services to the biological father
benefit the child.
will
will not
18.
The mother is incarcerated and is seeking to participate in the Department of Corrections and Rehabilitation community
treatment program.
a.
Participation in the program
in the child's best interest.
is
is not
b.
The program
suitable to meet the needs of the mother and child.
is
is not
The following person is incarcerated:
19.
mother
legal guardian
other
(specify):
presumed father
Indian custodian
and reasonable reunification services are
a.
granted.
b.
denied, because, by clear and convincing evidence, providing reunification services would be detrimental to the
child.
20.
As provided in Welf. & Inst. Code, § 361.5(b), by clear and convincing evidence:
mother
legal guardian
a. The
other
(specify):
presumed father
Indian custodian
is a person described in Welf. & Inst. Code, § (specify):
361.5(b)(3)
361.5(b)(7)
361.5(b)(9)
361.5(b)(11)
361.5(b)(13)
361.5(b)(16)
361.5(b)(4)
361.5(b)(8)
361.5(b)(10)
361.5(b)(12)
361.5(b)(15)
361.5(b)(17)
and reunification services are
(1)
granted, because, by clear and convincing evidence, reunification is in the best interest of the child.
(2)
denied.
b. The
mother
legal guardian
other
(specify):
presumed father
Indian custodian
is a person described in Welf. & Inst. Code, § 361.5(b)(1), and a reasonably diligent search has failed to locate the person.
Reunification services are denied.
mother
legal guardian
c. The
other
(specify):
presumed father
Indian custodian
is a person described in Welf. & Inst. Code, § 361.5(b)(2), and reunification services are
(1)
granted.
(2)
denied, because the person, even with the provision of services, is unlikely to be capable of adequately caring for
the child within the statutory time limits.
mother
legal guardian
d. The
other
(specify):
presumed father
Indian custodian
is a person described in Welf. & Inst. Code, § 361.5(b)(5), and reunification services are
(1)
granted, because
(a)
reunification services are likely to prevent reabuse or neglect.
(b)
the failure to try reunification will be detrimental to the child because the child is closely and positively bonded to
the person.
(2)
denied.
JV-421 [Rev. January 1, 2018]
DISPOSITIONAL ATTACHMENT: REMOVAL FROM
Page 3 of 7
CUSTODIAL PARENT
PLACEMENT WITH
NONPARENT
(Welf. & Inst. Code, §§ 361, 361.2)
JV-421
CHILD'S NAME:
CASE NUMBER:
20. e. The
mother
legal guardian
presumed father
Indian custodian
other
person who is a legal parent of the child (name):
is a person described in Welf. & Inst. Code, § 361.5(b)(6), and reunification services are
(1)
granted, because, by clear and convincing evidence, reunification is in the best interest of the child.
(2)
denied, because the child or the child's sibling suffered severe sexual abuse or the infliction of severe physical harm
by the person, and it would not benefit the child to pursue reunification with that person.
(3)
The factual basis for the findings in this item is stated on the record.
mother
legal guardian
f. The
other
(specify):
presumed father
Indian custodian
is a person described in Welf. & Inst. Code, § 361.5(b)(14). The court advised the person of any right to services and the
possible consequences of a waiver. The person executed the Waiver of Reunification Services (Juvenile Dependency) (form
JV-195), and the court accepts the waiver, the person having knowingly and intelligently waived the right to services.
Reunification services are denied.
g. The county agency must provide reunification services, and the following must participate in the reunification services
stated in the case plan:
Mother
Biological father
Legal guardian
Presumed father
Indian custodian
Other
(specify):
21.
The likely date by which the child may be returned to and safely maintained in the home or another permanent plan selected is
(specify):
Efforts
22.
The county agency
has
has not
complied with the case plan by making reasonable efforts to return the child to
a safe home through the provision of reasonable services designed to aid in overcoming the problems that led to the initial removal
and continued custody of the child and by making reasonable efforts to complete any steps necessary to finalize the permanent
placement of the child.
23. The following persons have made the indicated level of progress toward alleviating or mitigating the causes necessitating
placement:
None
Minimal
Adequate
Substantial
Excellent
a.
Mother
b.
Presumed father
c.
Biological father
d.
Legal guardian
e.
Indian custodian
f.
Other
(specify):
Siblings
The child does not have siblings under the court's jurisdiction.
24.
25.
The child has siblings under the court's jurisdiction. Sibling Attachment: Contact and Placement (form JV-403) is
attached and incorporated by reference.
DISPOSITIONAL ATTACHMENT: REMOVAL FROM
JV-421 [Rev. January 1, 2018]
Page 4 of 7
CUSTODIAL PARENT
PLACEMENT WITH
NONPARENT
(Welf. & Inst. Code, §§ 361, 361.2)
JV-421
CHILD'S NAME:
CASE NUMBER:
Health and education
The
mother
biological father
Indian custodian
26.
presumed father
legal guardian
other
(specify):
is
unable
unwilling
unavailable
to make decisions regarding the child's needs for medical,
surgical, dental, or other remedial care, and the right to make these decisions is suspended under Welf. & Inst. Code, § 369
and vested with the county agency.
27. a.
A limitation on the right of the parents to make educational decisions for the child is not necessary. The parents hold
educational rights and responsibilities in regard to the child's education, including those described in rule 5.650(e) and (f)
of the California Rules of Court. A copy of rule 5.650(e) and (f) may be obtained from the court clerk.
b.
A limitation on the right of the parents to make educational decisions for the child is necessary and those rights are limited
as stated in Order Designating Educational Rights Holder (form JV-535) filed in this matter. The educational rights and
responsibilities of the educational representative are described in rule 5.650(e) and (f) of the California Rules of Court. A
copy of rule 5.650(e) and (f) may be obtained from the court clerk.
are
are not
28. a. The child's educational needs
being met.
are
are not
b. The child's physical needs
being met.
are
are not
c. The child's mental health needs
being met.
are
are not
d. The child's developmental needs
being met.
The child
does
does not
have an order authorizing psychotropic medication. The next hearing to review the
29.
psychotropic medication order is on (date):
.
30.
The additional services, assessments, and/or evaluations the child requires to meet the unmet needs specified in item 28 or
other concerns are:
a.
stated in the social worker's report.
b.
specified here:
31.
The following persons are ordered to take the steps necessary for the child to begin receiving the services, assessments,
and/or evaluations identified in item 30:
a.
Social worker.
b.
Parent
(name):
c.
Surrogate parent
(name):
d.
Educational representative
(name):
e.
Other
(name):
The child's education placement has changed since the date the child was physically removed from the home.
32.
a.
The child's educational records, including any evaluation regarding a disability, were requested by the child's new school
within two business days of the request to enroll, and those records were provided by the child's former school to the
child's new school within two business days of the receipt of the educational records request.
b.
The child is enrolled in school.
c.
The child is attending school.
Child 14 years of age or older:
33.
a.
The services stated in the case plan include those needed to assist the child in making the transition from foster care to
successful adulthood.
The services stated in the case plan do not include those needed to assist the child in making the transition from foster
b.
care to successful adulthood.
c.
To assist the child in making the transition to successful adulthood, the county agency must add to the case plan and
provide the services
(1)
stated on the record.
(2)
as follows:
DISPOSITIONAL ATTACHMENT: REMOVAL FROM
JV-421 [Rev. January 1, 2018]
Page 5 of 7
CUSTODIAL PARENT
PLACEMENT WITH
NONPARENT
(Welf. & Inst. Code, §§ 361, 361.2)