0% found this document useful (0 votes)

31 views385 pages

Dc500sjuvenile 1

Uploaded by

bad.habitsrepair

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

0% found this document useful (0 votes)

31 views385 pages

Dc500sjuvenile 1

Uploaded by

bad.habitsrepair

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

You are on page 1/ 385

COURT CASE FORMS –

JUVENILE
DC-500 SERIES

DISTRICT COURT MANUAL

FORMS VOLUME
Form DC-501 ORDER TO CLOSE HEARING Form DC-501

Using This Form

This order is prepared by the judge of the juvenile and domestic relations district court,
when upon the motion of the Commonwealth’s Attorney, a defense attorney or sua sponte, the
judge finds cause to close a juvenile felony hearing which would otherwise be a public hearing.

1. Copies

a. Original – to court.

2. Prepared by judge.

3. Attachments – none.

4. Preparation details

The judge completes the order and it becomes a part of the public record in the case, even
though the hearing is closed. Virginia Code § 16.1-302. Data Element No. 7 must be
completed, indicating the judge’s reason for closing the hearing.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 1997
ORDER TO CLOSE HEARING 1
CASE NO. ....................................................................................
VA. CODE ANN. § 16.1-302

It appearing to the Court that

[ ] the above-named juvenile is fourteen years of age or older and is charged on a warrant or petition alleging an offense
which would be a felony if committed by an adult; OR
4
[ ] the above-named adult is charged with a crime,

the Court

[ ] sua sponte
5 [ ] on the motion of the accused

[ ] on the motion of the Commonwealth’s Attorney

ORDERS that the hearing scheduled in this matter on 6

........................................................................................ at .......................................................
DATE TIME

is hereby CLOSED to the public for the following reasons: 7

...........................................................................................................................................

and this order shall be made a part of the public record in this matter.

8
.......................................................................................... 9
______________________________________________________________
DATE JUDGE

FORM DC-501 (7/96) (MASTER)

Form DC-501 ORDER TO CLOSE HEARING Form DC-501

Data Elements

1. Court case number.

2. Court jurisdiction.

3. Style of the case – name of juvenile or adult accused.

4. Check appropriate box.

5. Check appropriate box indicating the party moving to close the hearing, or if closed spua
sponte.

6. Hearing date and time.

7. Judge’s reasons for closing or granting motion to close hearing.

8. Date order signed by judge.

9. Judge’s signature.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 1997
Form DC-502(A) Form DC-502(A)
Form DC-502(B) Form DC-502(B)
Form DC-502(C) PROCEEDINGS IN PETITIONS FOR Form DC-502(C)
Form DC-502(D) JUDICIAL AUTHORIZATION OF ABORTION Form DC-502(D)
Form DC-502(E) Form DC-502(E)

Using These Forms

These forms have been created to implement procedures for a petition seeking judicial
authorization for an abortion without parental notification. Virginia Code § 16.1-241(W).

All papers and hearings in these matters are confidential. No one is entitled to see these
files except the petitioner, her counsel and guardian ad litem. No notice of hearing is sent to the
parents of any juvenile filing the petition under this section.

The Juvenile and Domestic Relations District Court must hear these cases not later than
four days after the filing of the petition. Specific forms have been developed to deal with each
phase of the proceedings in the district court. An order denying judicial authorization of an
abortion may be appealed to the circuit court of the jurisdiction.
Form DC-502(A) PETITION FOR JUDICIAL AUTHORIZATION Form DC-502(A)
OF ABORTION

Using This Form

1. Copies

a. Original – to court.

b. First copy – to Petitioner, after completion of Data Element Nos. 13-17.

c. Second copy – to Petitioner's counsel.

d. Third copy – to guardian ad litem, if appointed.

2. Prepared by

a. Pro se petitioner at intake and by intake officer, and filed with clerk.

b. Petitioner and counsel for the petitioner and filed with clerk.

c. Clerk/intake officer completes Data Element Nos. 11-17.

3. Attachments – none.

NOTE: This is a master form and copies must be made by photocopying.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
PETITION FOR JUDICIAL AUTHORIZATION OF ABORTION Case No. . . . . . . . . . . . . . . . . . . . . . . . . . . .1
................................
Commonwealth of Virginia
Va. Code § 16.1-241-W Hearing Date and Time . . . . . . .2
................................

PLEASE NOTE: All papers and hearings in this matter are confidential.
3
............................................................................................................ Juvenile and Domestic Relations District Court
In re a petitioner under eighteen years of age:

5
....................................................... 5
.............................................. 5
............... ............................................
CONTACT TELEPHONE NUMBER (OPTIONAL) DATE OF BIRTH AGE

I, the undersigned, request this court to authorize a physician to perform an abortion pursuant to Virginia Code § 16.1-241(W).
I verify that the information given above is correct, and that I have elected not to seek consent of an authorized person as defined in
Virginia Code § 16.1-241(W).

6
................................................................... 7
_____________________________________________________
DATE PETITIONER'S SIGNATURE

Sworn/affirmed and signed before me on . . . . . . . . . .8. . . . . . . . . . . . . 9

_____________________________________________________
DATE
[ ] CLERK [ ] DEPUTY CLERK [ ] INTAKE OFFICER
[ ] NOTARY PUBLIC My commission expires: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Filed by: [ ] Petitioner with Intake Officer
[ ] Counsel for Petitioner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SIGNATURE OF COUNSEL

Date and Time Petition Filed: . . . . . . . . . . . . . . . . . . . . .11

............................ 12
_____________________________________________
[ ] CLERK [ ] DEPUTY CLERK [ ] INTAKE OFFICER

HEARING DATE

A hearing on this petition has been set for . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , at . . . . . . . . . . . . . . . . . . . m.,
DATE TIME

in the . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Juvenile and Domestic Relations District Court

15
..................................................................................................................................................................................
ADDRESS AND COURTROOM COURT TELEPHONE NUMBER

16
............................................................ 17
_________________________________________
DATE [ ] CLERK [ ] DEPUTY CLERK [ ] INTAKE OFFICER

ACKNOWLEDGEMENT OF HEARING DATE AND TIME

1. I understand that a hearing on this petition has been scheduled as noted above.

2. I acknowledge that I have received a copy of this petition and notice of hearing in person on this date. I waive all other forms of
notice for hearing on this date.

18
........................................................................ 19
__________________________________________
DATE PETITIONER'S SIGNATURE

___________________________________________________________ 20
SIGNATURE OF COUNSEL FOR THE PETITIONER

FORM DC-502A MASTER 07/12

Form DC-502(A) PETITION FOR JUDICIAL AUTHORIZATION Form DC-502(A)
OF ABORTION

Data Elements

1. Court case number.

2. Hearing date and time.

3. Court jurisdiction.

4. Petitioner's name.

5. Petitioner's current telephone number, date of birth, and age. Telephone number is clearly
marked as an optional data field. A petitioner should not be required to complete this data
field.

6. Date petition is signed by petitioner.

7. Petitioner's signature.

8. Date of affirmation.

9. Signature of person administrating oath. Notary public should show date commission expires.

10. Check appropriate box. If filed by an attorney for the petitioner, attorney's signature.

11. Date and time petition filed with clerk/intake officer.

12. Signature of clerk/intake officer.

13. Date and time of hearing on the petition.

14. Name of court that will hear the case.

15. Address and telephone number of court; and specific courtroom in which hearing will be held, if
known at the time of the filing of the petition.

16. Date on which hearing date is set.

17. Signature of clerk/intake officer who tells petitioner of hearing date and time.

18. Date on which petitioner acknowledges receipt of a copy of the petition and of the notice of
hearing.

19. Petitioner's signature.

20. Counsel's signature, if applicable.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
Form DC-502(B) ADVISEMENT OF YOUR RIGHT Form DC-502(B)
TO COUNSEL

Using This Form

This form was created to provide a quick, effective method for conveying to the
petitioner her right to counsel in petitions filed pursuant to Virginia Code § 16.1-241(W).

This form may be pre-signed by the judge if local policy permits, so that the clerk or
intake officer may review the information with the petitioner.

1. Copies

a. Original – to court.

b. First copy – to petitioner.

2. Signed by judge and by petitioner.

3. Attachments – none.

4. Preparation details

Because of the short time period involved in cases brought pursuant to § 16.1-241(W), all
preparation should be expedited. It is recommended that courts develop a written policy
regarding the ability of the clerk’s office or the intake office to review this form with
petitioner, when pre-signed by the judge, in those instances where a judge is not available
to advise the petitioner at the time the petition is filed.

NOTE: This is a master form and must be copied by photocopying.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
ADVISEMENT OF YOUR RIGHT TO COUNSEL
Commonwealth of Virginia
Va. Code § 16.1-241(W)
Case No. 1
........................................................

Hearing Date and Time 2

.................................

PLEASE NOTE: All papers and hearings in this matter are confidential.

[ ] Circuit Court
3
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Juvenile and Domestic Relations District Court

In re: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , a Petitioner under eighteen years of age

PETITIONER'S NAME

TO THE PETITIONER:

You have filed a petition asking for a judge to authorize a physician to perform an abortion to terminate
your pregnancy, without the physician having to obtain consent from a parent, legal guardian or custodian, or
other person with whom you regularly reside, as the law would otherwise require.

The Court is required to advise you that you have the right to be represented by a lawyer in this case. You
may retain a lawyer or, if you request it, the Court will appoint a lawyer to represent you. If the Court appoints a
lawyer to represent you, you will not be responsible for the lawyer's fee.

5
............................................................ 6
_______________________________________________
DATE JUDGE

This statement has been read and explained to me.

7
............................................................ 8
_______________________________________________
DATE PETITIONER'S SIGNATURE

FORM DC-502B MASTER 07/12

Form DC-502(B) ADVISEMENT OF YOUR RIGHT Form DC-502(B)
TO COUNSEL

Data Elements

1. Court case number.

2. Hearing date and time.

3. Court jurisdiction. Check appropriate box for type of court.

4. Petitioner's name.

5. Date of judge's signature.

6. Judge's signature. May be pre-signed according to local policy.

7. Date that petitioner is advised of right to counsel.

8. Petitioner's signature.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
Form DC-502(C) ACKNOWLEDGMENT OF RIGHT TO Form DC-502(C)
AND APPOINTMENT OF COUNSEL

Using This Form

1. Copies (This is a master form and copies are to be made by photocopying.)

a. Original – to court.

b. First copy – to petitioner.

c. Second copy – to court-appointed counsel.

d. Third copy – to guardian ad litem.

2. Signed by petitioner, and by judge if counsel or guardian ad litem is appointed.

3. Attachments – none.

4. Preparation details

a. This form should be completed by the petitioner after her review of form DC-
502(B), ADVISEMENT OF YOUR RIGHT TO COUNSEL.

b. Pursuant to a local written policy, the clerk or intake officer may review this form
with the petitioner. The appointment of counsel is made by the judge when he
enters the order in the “Appointment of Counsel” portion of the form (Data
Element Nos. 8 and 9).

c. Only the judge may appoint a guardian ad litem.

d. Either Data Element No. 4 or Data Element No. 5 of this form will be filled out,
but not both.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
ACKNOWLEDGEMENT OF RIGHT TO COUNSEL AND
APPOINTMENT OF COUNSEL VA. CODE § 16.1-241(W) 1
Court Case No. .................................................................

PLEASE NOTE: All papers and hearings in this matter are confidential.

In Re 3
................................................................................................................................................................... , a Petitioner under eighteen years of age

4
ACKNOWLEDGEMENT OF ADVISEMENT AND
REQUEST FOR APPOINTMENT OF COUNSEL

I acknowledge that I have been informed this day of my right to representation by a lawyer in all hearings to
consider my petition to have a judge authorize an abortion. I request that the Court appoint a lawyer to represent me.

4a
...................................................................... 4b
_____________________________________________________________
DATE SIGNATURE OF PETITIONER

5
ACKNOWLEDGEMENT OF ADVISEMENT AND STATEMENT REGARDING
EMPLOYMENT OF COUNSEL

I acknowledge that I have been informed this day of my right to representation by a lawyer in all hearings to
consider my petition to have a judge authorize an abortion.

5a [ ] I have retained ...................................................................................................................................................................................................

to represent me concerning my petition.

5b [ ] I waive the right to be represented by a lawyer in the hearing held by this Court on my
petition.

5c
...................................................................... 5d
_________________________________________________________________
DATE SIGNATURE OF PETITIONER

APPOINTMENT OF COUNSEL
The Court:

6 [ ] at the request of the Petitioner, has appointed ................................................................................................................... as counsel for her,
7 [ ] has determined that the guardian ad litem should be appointed and the Court has appointed
....................................................................................................................................... as guardian ad litem for the Petitioner;

8
....................................................................................... 9
______________________________________________________________________
DATE JUDGE

FORM DC-502 (C) MASTER 07/12

Form DC-502(C) ACKNOWLEDGMENT OF RIGHT TO Form DC-502(C)
AND APPOINTMENT OF COUNSEL

Data Elements

1. Court case number.

2. Jurisdiction. Check box for type of court.

3. Petitioner’s name.

4. Complete if appointed counsel requested by petitioner.

4a. Date of request for counsel.

4b. Petitioner’s signature.

5. Complete if counsel retained or waived.

5a. Check if counsel retained and insert name of attorney.

5b. Check if right to representation is waived.

5c. Date of acknowledgment/waiver.

5d. Petitioner’s signature.

6. Check if Data Element No. 4 is completed. Indicate name of appointed counsel.

7. Check if guardian ad litem is appointed and indicate name of attorney.

8. Date order signed by judge.

9. Judge’s signature.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
Form DC-502(D) ORDER IN PROCEEDING FOR Form DC-502(D)
JUDICIAL AUTHORIZATION OF ABORTION

Using This Form

1. Copies (This is a master form and copies are to be made by photocopying.)

a. Original – to court.

b. First copy – attested copy of order to petitioner after entry.

c. Second copy – counsel for the petitioner.

d. Third copy – to guardian ad litem for petitioner.

2. Prepared by judge.

3. Attachments – none.

4. Preparation details

a. Data Element No. 5 should be used when granting or denying the petition after a
hearing is held.

b. Data Element No. 6 should be used if the court fails to hold a hearing on a
properly filed petition within the statutorily-required four (4) day period.

c. Data Element No. 7 should be used if the court dismisses the case if the petitioner
fails to appear at the hearing.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
ORDER IN PROCEEDING FOR JUDICIAL AUTHORIZATION OF ABORTION
Commonwealth of Virginia
Va. Code § 16.1-241(W) 1
Case No. ..........................................................................

PLEASE NOTE: All papers and hearings in this matter are confidential.
2
................................................................................................................................... Juvenile and Domestic Relations District Court

3
In re ................................................................................................................................................ a petitioner under eighteen years of age:
4
...................................................................... 4
............................ ..........................................................
DATE OF BIRTH AGE

ORDER
[ ] Following a hearing held on the petition for judicial authorization of an abortion without the consent of an authorized
person as defined in Virginia Code § 16.1-241(W), it is the finding of this Court that

[ ] The Petitioner is mature enough and well enough informed to make her abortion decision. Therefore, in
consultation with her physician, independent of the wishes of any authorized person, the Petition is
GRANTED and a physician is authorized to perform the proposed abortion on the Petitioner without the
consent of an authorized person.

[ ] The Petitioner is not mature enough or well enough informed to make her abortion decision and, therefore,
the Court has determined whether the performance of an abortion without the consent of an authorized
person would be in the best interest of the Petitioner.

[ ] Because the Court finds that the abortion would be in the Petitioner’s best interest, the petition is
GRANTED and a physician is authorized to perform the abortion on the Petitioner without consent
of an authorized person.
5
[ ] The physician must give notice of the intent to perform an abortion to an authorized
person.

[ ] Notice to an authorized person is not required because it is not in the best interest of the
Petitioner.

[ ] Because the Court finds that the abortion would not be in the Petitioner’s best interest, the petition
is DENIED.

NOTICE TO THE PETITIONER: If your petition is denied, you have the right to appeal this decision to the
Circuit Court of this city or county. You must note your appeal with the Clerk of the Juvenile and Domestic
Relations District Court within ten (10) days of the petition being denied. The Circuit Court will hear and decide
your appeal no later than five (5) days after it is filed.

[ ] The Court has advised the Petitioner that she has the right to a confidential appeal of the decision of this
Court to deny authorization for an abortion without the consent of or without notice to an authorized person.
This appeal will be heard and decided by the Circuit Court no later than five (5) days after it is filed.
OR
6[ ] This Court did not act within the time period required by Virginia Code § 16.1-241(W). Therefore, a physician is
AUTHORIZED to perform an abortion on the Petitioner without the consent of or notice to an authorized person.
OR
7[ ] The petition is dismissed without prejudice because the petitioner did no appear at the hearing.

8
....................................................................................... 9
____________________________________________________
DATE JUDGE

FORM DC-502(D) MASTER 07/12

Form DC-502(D) ORDER IN PROCEEDING FOR Form DC-502(D)
JUDICIAL AUTHORIZATION OF ABORTION

Data Elements

1. Court case number.

2. Jurisdiction.

3. Petitioner’s name.

4. Petitioner’s date of birth and age.

5. Check the appropriate box which reflects the finding of the court after a hearing.

6. Check this box if the court did not take action within the time prescribed by statute.

7. Check this box if the petition is dismissed because petitioner did not appear at the
hearing.

8. Date order entered.

9. Judge’s signature.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
Form DC-502(E) NOTICE OF APPEAL – Form DC-502(E)
JUDICIAL AUTHORIZATION OF ABORTION

Using This Form

A petitioner whose petition for judicial authorization is denied may appeal to the circuit
court of the jurisdiction within ten (10) days of the judge’s decision. An order granting judicial
authorization of an abortion is not appealable. Because the circuit court must hear and decide the
case not later than five (5) days after the appeal, good coordination with the circuit court is
essential.

1. Copies

a. Original – to court.

b. First copy – to appellant (petitioner or petitioner’s counsel).

c. Second copy – to petitioner’s counsel.

2. Prepared by clerk, signed by appellant or appellant’s counsel.

3. Attachments – none.

4. Preparation details

Because of the short deadline involved in hearing an appeal of this type of case in circuit
court, the clerk should obtain the date and time of the circuit court hearing (Data
Element No. 8) while the petitioner is present.

NOTE: This is a master form and copies must be made by photocopying.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
NOTICE OF APPEAL – JUDICIAL AUTHORIZATION
OF ABORTION VA. CODE § 16.1-241(W) 1
Court Case No. ...........................................................

3
In re ................................................................................................................................................. , a Petitioner under the age of eighteen years
APPELLANT

TO: 4
........................................................................................................................................................................................... Circuit Court
CITY OR COUNTY

7
Date of Decision in Juvenile and Domestic Relations District Court ..........................................................................................................

DATE and TIME of appearance in Circuit Court: 8

................................................................................................................................................

I, the undersigned, note my appeal to the Circuit Court from the decision of the Juvenile and Domestic
Relations District Court denying my petition for the authorization of an abortion. I understand that my case will be
heard and decided by the Circuit Court no later than five (5) days after the filing of this appeal, and that my case will
remain confidential.

9
....................................................................................... 10
________________________________________________________________
DATE APPELLANT

by 11
____________________________________________________________
COUNSEL FOR APPELLANT

I have received a copy of this notice of appeal.

12
........................................................................................ 13
_____________________________________________________________
DATE APPELLANT

FORM DC-502(E) MASTER 07/12

Form DC-502(E) NOTICE OF APPEAL – Form DC-502(E)
JUDICIAL AUTHORIZATION OF ABORTION

Data Elements

1. Court case number.

2. Jurisdiction.

3. Petitioner’s name.

4. Jurisdiction of circuit court which will hear the case.

5. Street address of circuit court.

6. Telephone number of circuit court.

7. Date of juvenile court order.

8. Date and time of hearing in circuit court.

9. Date appeal noted.

10. Appellant’s signature, or name of appellant if noted by counsel.

11. Counsel’s signature, if applicable.

12. Date on which appellant received a copy of the completed form.

13. Appellant’s signature.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
DC-503 PETITION FOR APPROVAL OF STANDBY GUARDIAN Page: 1

Using This Form

1. Copies (Contact the court to determine if you should bring copies to the Clerk's Office or if copies will
be made upon filing.)

a. Original – to court

b. First Copy – to Petitioner

c. Other copies – should be provided to each person who is entitled to notice of the proceeding –
parents, if not petitioner, child, proposed standby guardian, proposed alternate standby guardian and
any others.

2. This form should be prepared by the Petitioner and acknowledged by the clerk, intake officer or a
notary public.

3. Data Elements #1-12 should always be completed. If approval of a proposed standby guardian is
requested, the petitioner should complete data elements #13-19. If approval of a designated standby
guardian is requested, data elements #20-25 should be completed.

3. If a designated standby guardian is requested, a copy of the written designation must be attached to the
petition.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
DC-503 PETITION FOR APPROVAL OF STANDBY GUARDIAN Page: 2

PETITION FOR COURT APPROVAL OF 1

Case No. ........................................................................
STANDBY GUARDIAN
Commonwealth of Virginia VA. CODE §§ 16.1-350, 16.1-352

2
........................................................................................................................................................ Juvenile and Domestic Relations District Court
In re ......................................................................................................................................................................,
3 a child under eighteen years of age
4
......................................................................................................................... 5
.......................................................................................................................
PETITIONER RELATIONSHIP OF PETITIONER TO CHILD

......................................................................................................................... 6
.......................................................................................................................
ADDRESS CHILD’S ADDRESS

......................................................................................................................... 7
.......................................................................................................................
CHILD’S DATE OF BIRTH

PARENTS
8
.........................................................................................................................
9
.......................................................................................................................
NAME OF FATHER NAME OF MOTHER

10 [ ] Father [ ] Mother is the qualified parent.

PROPOSED/DESIGNATED STANDBY GUARDIAN

11
......................................................................................................................... 12
.......................................................................................................................
NAME OF PROPOSED/DESIGNATED STANDBY GUARDIAN ALTERNATE PROPOSED STANDBY GUARDIAN

[ ] APPROVAL OF PROPOSED STANDBY GUARDIAN

1. The petitioner requests that 14
............................................................................................. be approved as the standby guardian
13 15 16
for ......................................................................................................... and ..................................................................................................................
be approved as the alternate.
2. The petitioner requests that the standby be given authority as a [ ] guardian of the person and/or
17 [ ] guardian of the property of the minor.
3. [ ] There is a significant risk that the qualified parent will imminently become physically or mentally
18 incapable of caring for the child or die as a result of a progressive chronic condition or illness. It is not
necessary for the Petitioner to produce medical records to establish this condition at the time of filing of
the petition.
4. The proposed triggering event is receipt by the standby guardian of a [ ] determination of incompetence or
certificate of death, whichever is earlier; OR [ ] written consent of the qualified parent and filing of the
19 consent with the Court upon the following conditions:
..............................................................................................................................................................................................................................................

FORM DC-503 (MASTER, PAGE ONE OF TWO) 7/98

Data Elements, page one of two
DISTRICT COURT MANUAL FORMS VOLUME
DECEMBER 2007
DC-503 PETITION FOR APPROVAL OF STANDBY GUARDIAN Page: 3

To be completed by the clerk

1. Court case number.

2. Court name.

3. Name of child for whom approval of standby guardian is requested.

4. Petitioner’s name and address.

5. Relationship of petitioner to child.

6. Child’s address.

7. Child’s date of birth.

8. Name and address of father.

9. Name and address of mother.

10. Check box to indicate which parent is the qualified parent under the definition in Virginia
Code § 16.1-349.

11. Name and address of proposed/designated standby guardian.

12. Name and address of alternate proposed standby guardian, if applicable.

13. Check if approval is requested for a proposed standby guardian.

14. Name of proposed standby guardian.

15. Name of child.

16. Name of alternate standby guardian, if applicable.

17. Check appropriate box(es).

18. Check this box to indicate that the petitioner is requesting this fact.

19. Check the box for the triggering event requested and indicate the conditions, if applicable.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
DC-503 PETITION FOR APPROVAL OF STANDBY GUARDIAN Page: 4

[ ] APPROVAL OF A DESIGNATED STANDBY GUARDIAN

1 2
1. [ ] A copy of the written designation of 3
...................................................................................... as standby guardian for
NAME OF STANDBY GUARDIAN

4
................................................................................................................ by 5
............................................................................................................
NAME OF CHILD NAME OF QUALIFIED PARENT
is attached.

2. The authority of the designated standby guardian has been triggered by

[ ] A determination of incompetence. A copy of the determination is attached.
6 [ ] The death of the qualified parent. A copy of the death certificate is attached.
[ ] A determination of debilitation and written consent by the qualified parent to commencement of the
authority of the standby guardian. A copy of the determination and the written consent is attached.

[ ] A determination of incompetence or debilitation has been made. Determination was made on ...............................
DATE
7 by ..............................................................................................................
NAME OF PHYSICIAN

The qualified parent’s attending physician is:

8
.........................................................................................................................................................................................................................................................
NAME AND ADDRESS OF ATTENDING PHYSICIAN

Reasons why the child’s other parent is not assuming or should not assume the responsibilities of a standby
guardian are: ...........................................................................................................................................................................................................................
9
.........................................................................................................................................................................................................................................................

10 There [ ] is [ ] is not any prior judicial history regarding custody of the child or any pending litigation
regarding custody of the child. If so, please provide details and case number, if known: .....................................................

11
........................................................................ 12
_____________________________________________________________________
DATE PETITIONER

The Petitioner appeared this date before the undersigned and, upon being duly sworn, made oath that the facts
stated in the foregoing petition are true based on the Petitioner’s knowledge.

13
........................................................................ 14
_____________________________________________________________________
DATE [ ] CLERK [ ] INTAKE OFFICER
[ ] NOTARY PUBLIC (My commission expires ....................................................... )

FORM DC-503 (MASTER, PAGE TWO OF TWO) 7/98

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
DC-503 PETITION FOR APPROVAL OF STANDBY GUARDIAN Page: 5

Data Elements, page two of two

1. Check box if approval of a designated standby guardian is requested.

2. Check this box and attach a copy of the designation.

3. Name of standby guardian.

4. Name of child.

5. Name of qualified parent.

6. Check appropriate box(es) for the triggering event.

7. If applicable, check box and provide date and name of physician.

8. Name and address of qualified parent’s attending physician.

9. Insert requested information.

10. Check appropriate box and provide information if applicable and known.

11. Date of signing of petition.

12. Petitioner’s signature.

To be completed by person acknowledging the signature of petitioner:

13. Date of acknowledgment.

14. Signature of person taking acknowledgment. Check the appropriate box below the signature line,
and if notarized, insert date of expiration of notary’s commission.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-504 NOTICE OF PETITION FOR COURT Form DC-504
APPROVAL OF STANDBY GUARDIAN

Using This Form

1. Prepared by the clerk and signed by the judge or the clerk.

2. The original should be retained by the court and copies sent to each parent, child,
proposed standby guardian and alternate, if any, and any other proper or necessary
parties.

3. Copies of district court form DC-503, PETITION FOR APPROVAL OF STANDBY GUARDIAN,
and summonses for everyone other than the parents, should be attached.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 1998
NOTICE OF PETITION FOR COURT 1
Case No.: ...........................................................................
APPROVAL OF STANDBY GUARDIAN
Commonwealth of Virginia VA. CODE § 16.1-350

2
.......................................................................................................................................... Juvenile and Domestic Relations District Court

In re 3
....................................................................................................................................................... , a child under eighteen years of age

4
............................................................................................................ 5
............................................................................................................
PETITIONER RELATIONSHIP OF PETITIONER TO CHILD

............................................................................................................ 6
............................................................................................................
ADDRESS CHILD’S ADDRESS

............................................................................................................ 7
............................................................................................................
CHILD’S DATE OF BIRTH

PARENTS
8
............................................................................................................ 9
............................................................................................................
NAME OF FATHER NAME OF MOTHER

10 [ ] Father [ ] Mother is the qualified parent.

PROPOSED STANDBY GUARDIAN

11
............................................................................................................ 12
............................................................................................................
NAME OF PROPOSED/DESIGNATED STANDBY GUARDIAN ALTERNATIVE PROPOSED/DESIGNATED STANDBY GUARDIAN

13 [ ] Petitioner has requested that .................................................................................... be approved to serve as standby guardian

NAME OF PROPOSED/DESIGNATED STANDBY GUARDIAN

for ................................................................................... upon the occurrence of [ ] determination of incompetence or death

CHILD’S NAME

of the qualified parent; and/or [ ] written consent of the qualified parent and filing of the consent with the
Court; and/or [ ] determination of debilitation and written consent to commencement of authority of the
standby guardian.
OR
14 [ ] Petitioner/Designated Standby Guardian has requested that the court approve his/her designation as standby
guardian since, within the last thirty (30) days, [ ] a determination of incompetence of the qualified parents has
been made, [ ] the death of the qualified parent has occurred, or [ ] a determination of debilitation has been
made and the qualified parent consented to commencement of the authority of the standby guardian. Petitioner
has produced to the Court a copy of the written designation by the qualified parent.

[ ] You may request a hearing within ten days of this notice.

15
[ ] A hearing will be held on ..............................................................................................
DATE AND TIME

It is not necessary that you appear at the hearing. No change in custody or other legal rights are effected
by the appointment of a standby guardian.

16
........................................................................ 17
___________________________________________________________
DATE [ ] JUDGE [ ] CLERK

FORM DC-504 MASTER 12/98

Form DC-504 NOTICE OF PETITION FOR COURT Form DC-504
APPROVAL OF STANDBY GUARDIAN

Data Elements

1. Court case number.

2. Name of court.

3. Name of child for whom approval of standby guardian is required.

4. Petitioner’s name and address.

5. Relationship of petitioner to child.

6. Child’s address.

7. Child’s date of birth.

8. Name and address of father.

9. Name and address of mother.

10. Check the appropriate box.

11. Name and address of proposed/designated standby guardian.

12. Name of alternate, if applicable.

13. Check this box if approval of proposed standby guardian is requested and provide name
of proposed standby guardian, name of child and check the requested triggering event.

14. Check this box if designated standby guardian is requesting approval and check the
applicable triggering event.

15. Check the appropriate box and if applicable, provide date and time of hearing.

16. Date and signing.

17. Signature of judge or clerk.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 1998
Form DC-505 ORDER APPROVING STANDBY GUARDIAN Form DC-505

Using This Form

1. This form is to be completed and signed by the judge.

2. Data Element Nos. 1-10 should always be completed. If approval of a proposed standby
guardian is requested, Data Element Nos. 11-14 should be completed. If approval of a
designated standby guardian is requested, Data Element Nos. 15-19 should be completed.

3. The original should be retained by the court and copies should be served on the standby
guardian and the alternate, if any.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 1998
ORDER APPROVING STANDBY GUARDIAN Case No. 1
........................................................................................
Commonwealth of Virginia VA. CODE §§ 16.1-351, 16.1-352

In re 3
........................................................................................................................................................................................... , a child under eighteen years of age

4
.............................................................................................................................. 5
..............................................................................................................................
PETITIONER RELATIONSHIP OF PETITIONER TO CHILD

.............................................................................................................................. 6
..............................................................................................................................
ADDRESS CHILD’S ADDRESS

.............................................................................................................................. 7
..............................................................................................................................
CHILD’S DATE OF BIRTH

PARENTS
8
.............................................................................................................................. 9
..............................................................................................................................
NAME OF FATHER NAME OF MOTHER

10 [ ] Father [ ] Mother is the qualified parent.

APPROVAL OF PROPOSED STANDBY GUARDIAN

Having reviewed the evidence and considered the factors set out in Virginia Code § 20-124.3, the Court finds that:

1. The parent is a qualified parent, and

2. Appointment of a standby guardian is in the best interest of the child.

Therefore, it is hereby ordered that:

1. 11
...............................................................................................................................................................................................................................................................
NAME AND ADDRESS OF STANDBY GUARDIAN

12
is approved as a standby guardian for ...................................................................................................................................................................................
NAME OF CHILD

2. The authority of the standby guardian is effective upon receipt of a [ ] determination of incompetence or certificate of death of
13th e qualified parent, whichever is earlier; OR [ ] written consent of the qualified parent and filing of the consent with the Court

upon the following conditions: .................................................................................................................................................................................................

A copy of the certificate of death, determination of incompetence or consent of the qualified parent upon which the
standby guardian’s authority is based must be filed with the Court within thirty days following the qualified parent’s
death, determination of incompetence or consent. Failure to file within thirty days shall be grounds for the Court to
rescind the authority of the standby guardian.

3. e standby guardian shall have the powers and duties of a [ ] guardian of the person and/or [ ] guardian of the property of
14Th
the minor.

FORM DC-505 (MASTER, PAGE ONE OF TWO) 7/98

APPROVAL OF A DESIGNATED STANDBY GUARDIAN

Having reviewed the evidence, the Court finds that

1. 15
........................................................................................................................ was duly designated as standby guardian for
NAME OF STANDBY GUARDIAN

16
........................................................................................................................ 17
by .....................................................................................................................................
NAME OF CHILD NAME OF QUALIFIED PARENT

pursuant to this section and the designation has not been revoked;

2. The standby guardian’s authority has commenced upon the occurrence of the following:

[ ] A determination of incompetence has been made.

18 [ ] A determination of debilitation has been made and the qualified parent consented to commencement of the
authority of the standby guardian.
[ ] The qualified parent has died as evidenced by a death certificate.

3. The best interests of the child will be served by approval of the standby guardian.

4.19[ ] The petition was filed by an alternate standby guardian, and the designated standby guardian is unwilling or unable to
serve.

20
.......................................................................................... 21
______________________________________________________________
DATE JUDGE

FORM DC-505 (MASTER, PAGE TWO OF TWO) 7/98

Form DC-505 ORDER APPROVING STANDBY GUARDIAN Form DC-505

Data Elements

1. Court case number.

2. Court name.

3. Name of child for whom approval of standby guardian is requested.

4. Petitioner’s name and address.

5. Relationship of petitioner to child.

6. Child’s address.

7. Child’s date of birth.

8. Name and address of father.

9. Name and address of mother.

10. Check box to indicate which parent is the qualified parent under the definition in Virginia
Code § 16.1-349.

11. Insert name and address of standby guardian.

12. Insert name of child.

13. Check appropriate box and provide conditions if applicable.

14. Check appropriate box.

15. Insert name of standby guardian.

16. Insert name of child.

17. Insert name of qualified parent.

18. Check appropriate box.

19. Check box if applicable.

20. Date of signing of order.

21. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 1998
Form DC-506 Form DC-506
NOTICE OF REVOCATION/STATEMENT
OF REFUSAL – STANDBY GUARDIAN

Using This Revisable PDF Form

1. This form is prepared by the qualified parent or the standby guardian.

2. The person filing this form is required to serve it on the other party. The court is not required
to take any action in response to the filing of this form.

3. Data elements No. 1-9 should always be completed. If the qualified parent is revoking the
standby guardian’s authority, data elements No. 10-15 should be completed. If the standby
guardian is declining to serve, data elements No. 14-16 should be completed.
NOTICE OF REVOCATION/STATEMENT OF Case No.: .....
1 ...............................
REFUSAL — STANDBY GUARDIAN
Commonwealth of Virginia VA. CODE § 16.1-354

2 ...................................................................................................................................... Juvenile and Domestic Relations District Court

In re ..... 3 ................................................................................................... , a child under eighteen years of age

................................... 4 ...........................................................................................................................................
CHILD’S ADDRESS

PARENTS

5 .......................................................................... . 6 ........................................................................
NAME OF FATHER NAME OF MOTHER

..................................................................................... .....................................................................................
ADDRESS ADDRESS

7 ........................................................................... .....................................................................................

[ ] Father [ ] Mother is the qualified parent.

APPROVED STANDBY GUARDIAN

.
8 .............................................................................................. 9 .........................................................................................
NAME OF STANDBY GUARDIAN ALTERNATE STANDBY GUARDIAN

[ ] s dby guardian [ ] alternate standby guardian. A copy of this revocation has been delivered to
13
..... ......................................................................................................... whose authority is being revoked by this document.
AME OF STANDBY GUARDIAN/ALTERNATE STANDBY GUARDIAN

14 [ ] STATEMENT OF REFUSAL
I, 15 .......................................................... , hereby decline to serve as a standby guardian for
NAME OF STANDBY GUARDIAN

16 .................................................................................... The qualified parent and any alternate standby guardian have been
NAME OF CHILD
personally served with this statement of refusal.

17 18
......................................................................... _ ____________________________________
DATE SIGNATURE OF PARENT/STANDBY GUARDIAN

FORM DC-506 (MASTER) REVISED 7/98

Form DC-506 Form DC-506
NOTICE OF REVOCATION/STATEMENT
OF REFUSAL – STANDBY GUARDIAN

Data Elements

1. Court case number.

2. Court name.

3. Name of child for whom approval of standby guardian is requested.

4. Child’s address.

5. Name and address of father.

6. Name and address of mother.

7. Check appropriate box.

8. Name and address of standby guardian.

9. Name and address of alternate standby guardian, if applicable.

10. Check if notice of revocation by qualified parent.

11. Name of qualified parent.

12. Name of standby guardian and check appropriate box for title.

13. Name of standby guardian or alternate standby guardian.

14. Check if Statement of Refusal.

15. Name of standby guardian.

16. Name of child.

17. Date of signing.

18. Signature of parent or standby guardian.

Form DC-508 ACKNOWLEDGMENT OF NOTICE OF Form DC-508
NEXT HEARING DATE

Using This Form

1. Copies

a. Original – to the court.

b. Copies – to each person signing the acknowledgment.

2. Prepared by clerk, signed, initialed by parties and lawyers.

3. Attachments

a. Copy of order entered at court hearing at which this form is used.

4. Preparation details

a. This form was developed to be used in abuse and neglect, entrustment and foster
care placement cases to assist the courts in meeting statutory notice requirements
and is designed to provide notice of future hearing dates at the time parties are
before the court.

b. Provision of a copy of this notice at the hearing constitutes service of notice of the
future hearings listed.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2002
ACKNOWLEDGMENT OF NOTICE OF 1
Case No: ........................................................................................
NEXT HEARING DATE Commonwealth of Virginia
2
.................................................................................................................................................................. Juvenile and Domestic Relations District Court

3
In re: .........................................................................................................................................................................
CHILD

By my signature below, I acknowledge notice of the next hearing date and time specified below in the above-styled case. I also
acknowledge receipt of a copy of this ACKNOWLEDGMENT OF NOTICE OF NEXT HEARING DATE for the next court date and time
specified and of the court order on this date, if initialed by me below. I will inform the court if my address changes. The hearing will
be:

NEXT HEARING
DATE AND TIME

.............................................................. an adjudicatory hearing concerning a petition alleging child abuse or neglect pursuant to Virginia
Code § 16.1-252 or § 16.1-253.
.............................................................. a dispositional hearing resulting from a finding of abuse or neglect pursuant to Virginia Code
§ 16.1-252 or § 16.1-253. If the child has been placed in foster care, the foster care service plan
for the child will be reviewed at this hearing.
.............................................................. a dispositional hearing concerning the child placed in foster care pursuant to an order entered in
accordance with Virginia Code § 16.1-278.2 (abused or neglected child without preliminary
removal; child at-risk of abuse or neglect), § 16.1-277.02 or § 16.1-278.3 (relief of custody),
§ 16.1-278.4 (child in need of services), § 16.1-278.5 (child in need of supervision), § 16.1-278.6
(status offender), or § 16.1-278.8 (delinquent juvenile). The foster care service plan for the child
4 will be reviewed at this hearing.
.............................................................. a foster care review hearing pursuant to Virginia Code § 16.1-282.
.............................................................. a permanency planning hearing pursuant to Virginia Code § 16.1-282.1. At this hearing, the Court
will consider a permanent placement for the child who is the subject of these proceedings.
.............................................................. a semi-annual foster care review hearing pursuant to Virginia Code § 16.1-282.1 A2 concerning
the child placed in another planned permanent living arrangement.
.............................................................. an annual foster case review hearing pursuant to Virginia Code § 16.1-282.2.
.............................................................. a hearing to review progress in this case.
5
DATE OF ACKNOWLEDGMENT: ......................................................................................................................... ORDER RECEIVED (INITIALS):

FORM DC-508 (MASTER) REVISED 7/02

Form DC-508 ACKNOWLEDGMENT OF NOTICE OF Form DC-508
NEXT HEARING DATE

Data Elements

1. Insert court case number.

2. Insert name of court.

3. Insert name of child who is the subject of proceedings.

4. Insert applicable hearing dates and times.

5. Insert date of acknowledgments.

6. Insert names, addresses and signatures of persons involved in the proceeding.

7. Each person should check box if he or she received a copy of the order issued in
conjunction with the present hearing and initial beside the box.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2002
Form DC-509 AFFIDAVIT/CERTIFICATION OF Page: 1
PARENTAL IDENTITY OR LOCATION

Using This Form

This form may be used by a Juvenile and Domestic Relations District Court when, in a delinquency,
status or traffic proceeding, the location or address of the juvenile’s parent or guardian is unknown. If the
affidavit and certification are made for the record, the court may proceed in such cases without fulfilling
the statutory requirement for issuing a summons for the parent or guardian. Virginia Code § 16.1-263(E).

1. Copies

a. Original – to court.

b. Copies as determined by local practice.

2. Affidavit prepared by juvenile probation officer or law enforcement officer, signed by intake officer,
clerk or notary. Certification signed by judge.

3. Attachments – none.

4. Preparation details

a. The juvenile probation officer or law enforcement officer completes the affidavit portion of the
form (data elements 5-11), checking either data elements 6 and 7 or data elements 8 or 9.

b. After the completion of the affidavit, the judge must certify that, in the absence of other evidence,
the court on the basis of the affidavit regarding the location contained on the form or an affidavit
supplied by the other parent regarding the identity of a parent will proceed to hear the delinquency,
status or traffic case without a summons being issued to the absent parent or guardian (data
elements 19-23).

The judge may rely on other evidence of a parent’s identity not being reasonably ascertainable,
when completing data elements 16-18.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-509 AFFIDAVIT/CERTIFICATION OF Page: 2
PARENTAL IDENTITY OR LOCATION

AFFIDAVIT/CERTIFICATION OF PARENTAL Case No. 1

.............................................................................
IDENTITY OR LOCATION
Commonwealth of Virginia VA. CODE § 16.1-263

2
................................................................................................................................................... Juvenile and Domestic Relations District Court

3
....................................................... . .................................................. v./In re 4
............................................... ............................................................

AFFIDAVIT OF LOCATION
5
I swear or affirm that ................................................................................................................................................................. , a juvenile,
is charged with a delinquent act, crime, status offense or traffic infraction or is alleged to be in need of services
or of supervision, and that 7
6 [ ] the location of the juvenile’s [ ] mother [ ] father [ ] guardian is not reasonably ascertainable; OR
8 [ ] the location or mailing address of the juvenile’s [ ] mother [ ] father [ ] guardian, believed to be
outside the Commonwealth, is not reasonably ascertainable.
9
________________________________________________
10
[ ] JUVENILE PROBATION OFFICER [ ] LAW ENFORCEMENT OFFICER

________________________________________________
11
BADGE NO , AGENCY AND JURISDICTION

12
Commonwealth of Virginia, City/County of .................................................................................................... :

13 Subscribed and sworn to before me this the .................... day of ................................................................... , ..............................

My Commission Expires: 15
..................................................... 14
___________________________________________
[ ] INTAKE OFFICER [ ] NOTARY PUBLIC [ ] CLERK/DEPUTY CLERK

CERTIFICATION OF PARENTAL IDENTITY OR LOCATION

17
16 [ ] Pursuant to Va. Code § 16.1-263(E)(i), I certify that the identity of the [ ] mother [ ] father [ ] guardian
of
18
................................................................................................................................. , a juvenile, is not reasonably ascertainable.

19 [ ] Pursuant to Va. Code § 16.1-263(E)(ii), I certify that this case involves an allegation that,
................................................................................................... , a juvenile, has committed a delinquent act, crime, status offense
or traffic infraction or is alleged to be in need of services or of supervision, and
21
20[ ] the location of the juvenile’s [ ] mother [ ] father [ ] guardian is not reasonably ascertainable; OR
22[ ] the location or mailing address of the juvenile’s [ ] mother [ ] father [ ] guardian, believed to be
outside the Commonwealth, is not reasonably ascertainable. 23

24
........................................................................ __________________________________________________________25
DATE JUDGE

FORM DC-509 MASTER 12/98

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-509 AFFIDAVIT/CERTIFICATION OF Page: 3
PARENTAL IDENTITY OR LOCATION

Data Elements

1. Court case number. 19. Check box if applicable and state name of
juvenile.
2. Jurisdiction.
20. Check box if location of parent is not
3. Name of plaintiff or of prosecuting entity reasonably ascertainable.
(Commonwealth or locality).
4. Name of juvenile or defendant. 21. Indicate which parent is the subject of the
certification.
5. Name of juvenile.
22. Check box if parent or guardian is believed to
6. Check box if applicable. be outside the Commonwealth.

7. Indicate which parent is the subject of the 23. Indicate which parent is the subject of the
affidavit. certification.

8. Check box if applicable. 24. Date of certification.

9. Indicate which parent is the subject of the 25. Judge’s signature.

affidavit.

10. Signature of affiant. Check appropriate box.

11. Badge number, agency and jurisdiction of law

enforcement officer.

12. Jurisdiction in which affidavit was taken.

13. Date of affidavit.

14. Signature of individual administering oath.

Check appropriate box.

15. Notary commission expiration date, if

applicable.

16. Check box if identity of parent is not

reasonably ascertainable.

17. Indicate which parent is the subject of the

certification.

18. Juvenile’s name.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-510 SUMMONS Form DC-510
(JUVENILE AND DOMESTIC RELATIONS DISTRICT COURT)

Using This Form

1. Copies

a. Original – to sheriff to be executed, then to court.

b. Copies to each person listed in “Persons to be Served,” Data Element No. 11.

2. Prepared by clerk or judge, executed by serving officer.

3. Attachments

a. Form DC-511, JUVENILE PETITION.

b. Form DC-535, NOTICE OF TERMINATION OF RESIDUAL PARENTAL RIGHTS (in applicable

cases).

c. Form DC-610, PETITION FOR SUPPORT (CIVIL).

d. Form DC-611, PETITION FOR PROTECTIVE ORDER (ADULT).

e. Form DC-612, DESERTION/NON-SUPPORT PETITION (CRIMINAL).

f. Other case-initiation documents for which no other service of process forms are provided.

g. Form DC-413, CERTIFICATE OF MAILING (if used).

4. Preparation details

a. If more than five sheets (original plus four copies) are being prepared, the last copy
should be examined for legibility. If not legible, determine how many copies are illegible
and make duplicate copies (front and back) from the original using a copier to replace the
illegible copies.

b. To expedite service of process, put multiple parties on the same summons only when all
such parties live in the same household or when the same serving officer will be used to
serve all parties listed on the summons. Otherwise, use a separate summons for each
party.

c. Notice of rights to representation by a lawyer is printed on the reverse side of this

summons. In addition, notice of the responsibility of parents or guardians to pay the cost
of a guardian ad litem for a child is printed on the reverse. Notice of potential liability
for child support regarding certain removal actions is also printed on the reverse.

d. If service of process is obtained by posted service, a party who mails a copy to the other
parties being served mail execute the certificate of mailing on the back or may file form
DC-413, CERTIFICATE OF MAILING.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2009
SUMMONS Case No. 1
.....................................................................................
COMMONWEALTH OF VIRGINIA

2
............................................................................................................................................................... Juvenile and Domestic Relations District Court
3
...............................................................................................................................................................................................................................................................................
COURT’S STREET ADDRESS AND TELEPHONE NUMBER

4
.................................................................................................................................... v./In re .........................................................................................................................

HEARING DATE HEARING TIME

5 6

TO ANY AUTHORIZED OFFICER: I COMMAND YOU to summon the parties as designated below.
TO THE PERSON SUMMONED: I COMMAND YOU to appear before this Court at the date, place and time specified in this
Summons to respond to the allegations in the attached documents in accordance with the provisions of the Juvenile and Domestic
Relations District Court Law. Failure to appear at Court may subject you to contempt of court proceedings.
NOTE: READ THE NOTICE ABOUT RIGHT TO REPRESENTATION BY A LAWYER ON THE BACK OF THIS SUMMONS.
DOCUMENT(S) ATTACHED.
7 [ ] PETITION [ ] Notice of Termination of Residual Parental Rights [ ] Notice to Respondent in Enforcement Proceeding
(District Court Form DC-535) Under Virginia Code § 20-146.29 of the Uniform
8 [ ] Notice of change in date and/or time of hearing Child Custody Jurisdiction and Enforcement Act
9 [ ] Notice to juvenile to show cause why the juvenile’s driver’s license should not be suspended under Virginia Code § 46.2-334.001.
10
[ ] .......................................................................................................................................................................................................................................................................
11
....................................................................... 12
___________________________________________________________________________
DATE ISSUED [ ] CLERK [ ] JUDGE

DISABILITY ACCOMMODATIONS for loss of hearing, vision, mobility, etc., contact the court ahead of time.
RETURNS: Each person was served according to law, as indicated below, unless not found.

13
NAME ..................................................................................... NAME ..................................................................................... NAME .....................................................................................

...................................................................................... ...................................................................................... ......................................................................................

ADDRESS ............................................................................... ADDRESS ............................................................................... ADDRESS ..............................................................................

...................................................................................... ...................................................................................... ......................................................................................

Tel. Tel. Tel.
[ ] PERSONAL SERVICE No. .............................. [ ] PERSONAL SERVICE No. .............................. [ ] PERSONAL SERVICE No. ..............................
14
[ ] Being unable to make personal service, a copy [ ] Being unable to make personal service, a copy [ ] Being unable to make personal service, a copy
was delivered in the following manner: was delivered in the following manner: was delivered in the following manner:

[ ] Delivered to family member (not temporary [ ] Delivered to family member (not temporary [ ] Delivered to family member (not temporary
sojourner or guest) age 16 or older at usual place sojourner or guest) age 16 or older at usual place sojourner or guest) age 16 or older at usual place
of abode of party named above after giving of abode of party named above after giving of abode of party named above after giving
information of its purport. List name, age of information of its purport. List name, age of information of its purport. List name, age of
recipient, and relation of recipient to party named recipient, and relation of recipient to party named recipient, and relation of recipient to party named
above. above. above.
15
16
...................................................................................... .................................................................................... ......................................................................................

...................................................................................... .................................................................................... ......................................................................................

[ ] Posted on front door or such other door as [ ] Posted on front door or such other door as [ ] Posted on front door or such other door as
appears to be the main entrance of usual place of appears to be the main entrance of usual place of appears to be the main entrance of usual place of
abode, address listed above. (Other authorized abode, address listed above. (Other authorized abode, address listed above. (Other authorized
recipient not found.) recipient not found.) recipient not found.)

[ ] Not found [ ] Not found [ ] Not found

17 18
____________________________ ___________________________ ___________________________
SERVING OFFICER SERVING OFFICER SERVING OFFICER

19
.............................. for ________________________20 .............................. for _______________________ .............................. for _______________________
DATE DATE DATE

SUMMONS CASE NO. .................................................................................

FORM DC-510 (MASTER, PAGE ONE OF TWO) 07/09
Form DC-510 SUMMONS Form DC-510
(JUVENILE AND DOMESTIC RELATIONS DISTRICT COURT)

Data Elements, page one

1. Court case number.

2. Court name.

3. Street address and telephone number of court.

4. Court name. In juvenile cases, insert “Commonwealth of Virginia” in first blank and the
child’s name in the second blank on the same line.

5. Date of hearing.

6. Time of hearing.

7. Check the appropriate box(es) if form DC-535, PETITION, NOTICE OF TERMINATION OF

RESIDUAL PARENTAL RIGHTS, or NOTICE TO RESPONDENT is attached.

8. Check box if SUMMONS is used as notice to parties of a continuance.

9. Check box if SUMMONS is used as notice to juvenile of possible license suspension under Va.
Code § 46.2-334.001.

10. Check and insert description of other documents attached to summons which are not included
in Data Element No. 7.

11. Date of issuance.

12. Signature of judge or clerk. Check appropriate box.

13. Name and address (and telephone number if known) of party to be served (to be inserted by
clerk or judge).

14. Serving officer to check this box if personal service obtained.

15. Serving officer to check the appropriate box to designate type of substitute service.

16. If served by leaving a copy with a family member age 16 or older, check appropriate box and
insert required information.

17. Serving officer to check this box if unable to serve process.

18. Signature of serving officer.

19. Date of signature.

20. Name of sheriff if served by deputy sheriff.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2009
Va. Code § 16.1-266
RIGHT TO REPRESENTATION BY A LAWYER
A lawyer may be appointed only in those cases described below.
NOTE: In determining whether a person is entitled to a court-appointed lawyer or if a parent is financially able to pay for
a lawyer, such adult and, if applicable, the parents of a juvenile shall complete a financial statement form and sign a
statement of indigency.
The Court shall appoint a lawyer as guardian ad litem to represent any child alleged to be abused or neglected, or
for a child who is the subject of an entrustment agreement or of a petition seeking termination of residual parental rights
or consent to a parental placement adoption, or who is before the Court when the parent desires for good cause to be
relieved of care and custody.
Prior to a detention hearing, the Court shall appoint a lawyer to represent the child unless a lawyer has been
retained and appears on the behalf of the child, and the child’s indigence shall be presumed for the purposes of this
appointment only. Prior to any subsequent hearing by the Court of any case involving a child alleged to be in need of
services or supervision or alleged to be delinquent, such child has a right to be represented by a lawyer of the child’s own
choice, or, if the Court determines that the child is indigent within the contemplation of the law and his or her parents,
guardian, legal custodian, or other person standing in loco parentis does not retain a lawyer for the child, the Court shall
appoint a lawyer to represent the child unless an appropriate waiver of counsel has been accepted by the Court. A child
who is alleged to have committed an offense that would be a felony if committed by an adult may not waive the right to
counsel prior to consulting an attorney and the court determining that the waiver of the right to counsel is free and
voluntary.
If the Court appoints a lawyer to represent the child, and finds that the parents are financially able to pay for the
lawyer and refuse to do so, the Court shall assess the costs of legal services against the parents. The child in some cases
may waive his right to be represented by a lawyer, if the Court finds that the child and parents, guardian, legal custodian,
or other person standing in loco parentis, consent in writing and the interests of such individuals are not adverse.
Prior to a hearing by the Court of any case involving an adult who is charged with abuse or neglect of a child or at
which a parent could be subjected to the loss of residual parental rights, and prior to the adjudicatory hearing of a petition
in which a child is alleged to be abused or neglected or at risk of abuse or neglect, the child’s parent or guardian or the
adult has a right to representation by a lawyer of his own choice, and if such parent, guardian or adult is indigent, the
Court shall appoint a lawyer to represent him, and such parent, guardian or other adult may waive the right to
representation by a lawyer. In addition, the Court shall consider appointing a lawyer to represent the parent or guardian of
a child who is the subject of a foster care plan, foster care review or permanency planning hearing.
In all other cases, the Court in its discretion may appoint a lawyer or guardian ad litem to represent the interest of
the child or the parent or guardian. However, if a child’s custody is in dispute and the parents or other parties seeking
custody are represented by lawyers, no lawyer will be appointed to represent the child unless the judge finds that the
child’s interests are not otherwise adequately represented.
NOTICE REGARDING GUARDIANS AD LITEM: If you are a parent of a child for whom a guardian ad litem is
appointed in a proceeding or a party with a legitimate interest in such child, you will be required to reimburse the
Commonwealth for the cost of the guardian ad litem. The amount you are required to pay may not exceed the amount
awarded to the guardian ad litem by the court and it may be reduced or eliminated if the court determines that you are
unable to pay.
NOTICE REGARDING REMOVAL HEARINGS ONLY: If you are a parent, guardian, legal custodian or other
person standing in loco parentis to a child and if the child is the subject of a removal proceeding at which the court will
consider whether to remove the child from his/her home and the court determines that the child should be removed from
his/her home, the court will consider whether you should be required to pay child support for this child.
NOTICE REGARDING JUVENILE COMMITMENT: If you are a parent or other person legally obligated to care for
and support a juvenile who is the subject of a delinquency proceeding, you may be required to pay a reasonable sum for
the support of the juvenile if the juvenile is committed to the Department of Juvenile Justice or to a secure local facility.

I certify that I mailed a copy of this document to the parties named on the front at the address shown on the front on:
1
....................................................................... 2
____________________________________________________________________
DATE

FORM DC-510 (MASTER, PAGE TWO OF TWO) 10/06

Form DC-510 SUMMONS Form DC-510
(JUVENILE AND DOMESTIC RELATIONS DISTRICT COURT)

Date Elements, page two

1. Date that item was sent and certification made.

2. Signature of person making certification.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2009
Form DC-511 PETITION Form DC-511

Using This Form

1. Copies
a. Original – to court.
b. Copies to each person designated on the original copy to receive process.
c. Other copies as determined by local practice.
2. Prepared by petitioner and intake officer.
3. Attachments
a. Form DC-325, REQUEST FOR WITNESS SUBPOENA – if prepared at time of issuance of
petition.
b. Form DC-510, SUMMONS
c. Form DC-513, ADVISEMENT AND REQUEST FOR APPOINTMENT OF COUNSEL – at first
appearance in court (if form DC-515 not used).
d. Form DC-515, WAIVER OF RIGHT TO BE REPRESENTED BY A LAWYER (JUVENILE) – at first
appearance in court (if form DC-513 is not used).
e. Form DC-517, WAIVER OF JURISDICTION – if used in a court proceeding.
f. Form DC-519, NOTICE OF TRANSFER HEARING (if used) when transfer hearing is scheduled.
g. Form DC-526, EMERGENCY REMOVAL ORDER – if used (attach to all copies of petition if
order issued when petition is prepared).
h. Form DC-527, PRELIMINARY PROTECTIVE ORDER – if used (attach to all copies of petition if
order issued when petition is prepared).
i. Form DC-528, PRELIMINARY REMOVAL ORDER – if used (attach to all copies of petition if
order issued when petition is prepared).
j. Form DC-529, DETENTION ORDER – if used (attach to all copies of petition if order issued
when petition is prepared).
k. Form DC-535, NOTICE OF TERMINATION OF RESIDUAL PARENTAL RIGHTS – if used (attach
to all copies of petition in these proceedings).
l. Form DC-620, AFFIDAVIT (UNIFORM CHILD CUSTODY JURISDICTION ACT) – if used (attach
to all copies of petition in these proceedings).
m. Form DC-641, PARENTAGE SUPPLEMENT TO PETITION, if parentage is an issue.
4. Preparation details
a. If more than five sheets (original plus four copies) are being prepared, the last copy
should be examined to be sure that it is legible. If not legible, determine how many
copies are illegible and make duplicate copies from the original using a copier to replace
the illegible copies.
b. Data Element Nos. 15-17 (regarding placement in detention or shelter care) should be
updated on the original if the child is taken into custody after the petition has been issued.

DISTRICT COURT MANUAL FORMS VOLUME

JANUARY 2009
PETITION 1
Case No. ..........................................................................................
Commonwealth of Virginia VA. CODE §§ 16.1-262; 16.1-263
2
............................................................................................................
DATE OF HEARING
3
.................................................................................................................................................................. Juvenile and Domestic Relations District Court
In re a Child under eighteen years of age
CHILD’S NAME SSN: DATE OF BIRTH AGE SEX RACE
1. 4 2. 5 3. 6 M.F.
7 8
CHILD’S ADDRESS TELEPHONE NO.
4. 9
FATHER’S NAME SSN DATE OF BIRTH TELEPHONE NO.
5. 10
FATHER’S ADDRESS
6. 11
MOTHER’S NAME SSN DATE OF BIRTH TELEPHONE NO.
7. 12
MOTHER’S ADDRESS
8. 13
GUARDIAN/LEGAL CUSTODIAN OR PERSON IN LOCO PARENTIS NAME AND ADDRESS TELEPHONE NO
9. 14
GUARDIAN’S /LEGAL CUSTODIAN OR PERSON IN LOCO PARENTIS RELATIONSHIP TO CHILD
10. 15
OTHER(S) NAME AND ADDRESS TELEPHONE NO.
11. 16
12. Child held in CUSTODY [ ] Yes [ ] No 17
18
13. Place of Detention or Shelter Care ......................................................................................................................................................................................................

14. Date and Time Taken into Custody 13. Date and Time Placed in Detention or Shelter Care
19 20
_____ / _____ / _____ _____: _____ _____ m. ______ / ______ / ______ _____ : _____ _____ m.

15. The above information is not known to the petitioner: No(s). 21

I, the undersigned petitioner, state under oath to the best of my knowledge, that the above-named child is within the purview of the Juvenile and
Domestic Relations District Court Law in that, within this city/county, the child:
...............................................................................................................................................................................................................................................................................
22
...............................................................................................................................................................................................................................................................................
...............................................................................................................................................................................................................................................................................
...............................................................................................................................................................................................................................................................................
...............................................................................................................................................................................................................................................................................
(FOR ADMINISTRATIVE USE ONLY IN DELINQUENCY CASES) Virginia Crime Code: ...............................................................................................
WHEREFORE, the Petitioner requests that the child and the persons having his or her custody and control be summoned to appear before this Court,
and that this Court enter such orders and judgments as the Court deems fit and proper in accordance with the law and which will serve the purpose
and intent of the Juvenile and Domestic Relations District Court Law.

23
....................................................................... 24
....................................................................... 25
____________________________________________
DATE PETITIONER’S NAME (PRINT OR TYPE) PETITIONER’S SIGNATURE

26
...............................................................................................................................................................................................................................................................................
PETITIONER’S ADDRESS AND TELEPHONE NUMBER (COURT COPY ONLY)
27
Sworn/affirmed and signed before me on .........................................................................................................................................................................
28
Title: ................................................................................................. 29
Signature: _________________________________________________________

30
Filed by: ______________________________________________________________ 31
........................................................................
[ ] INTAKE OFFICER [ ] ATTORNEY DATE

FOR NOTARY PUBLIC’S USE ONLY:

State of ................................................................................................. [ ] City [ ] County of ....................................................................................................

32 Acknowledged, subscribed and sworn to before me this ............................ day of ................................................................................... , 20 .....................

......................................................................................... _______________________________________________________
NOTARY REGISTRATION NUMBER NOTARY PUBLIC
(My commission expires: ................................... )

FORM DC-511 (MASTER, PAGE ONE OF TWO) 01/09

Form DC-511 PETITION Form DC-511

Data Elements

1. Court file number. 19. If placed in detention, give the date and
time that the child was taken into official
2. Date of hearing. custody.
3. Name of Court. 20. If placed in detention, give the date and
4. Name and Social Security number of time that the child was placed in a
child who is the subject of this petition. detention or shelter care facility.

5. Date of birth of child. 21. Insert item numbers of information

petitioner could not provide.
6. Age of child in years. If less than one
year old, state age of child in months or NOTE: Do not place more than one charge
days and state if age is in months or or case on one petition. Separate petitions
years. should be filed per charge or matter, i.e.
7. Sex of child. Circle "M" or "F". petition for custody and separate petition for
visitation.
8. Race of child.
9. Street address and telephone number of 22. Description of charge or matter before
child. the court, i.e. custody determination or
visitation determination, including
10. Father's name, Social Security number, citations to statutes or ordinances.
date of birth, and telephone number.
23. Date of signature of petitioner.
11. Father's street address.
24. Print or type petitioner’s name.
12. Mother's name, Social Security number,
date of birth, and telephone number. 25. Signature of petitioner.

13. Mother's street address. 26. Petitioner’s street address and telephone
number (on court copy ONLY).
14. Name, street address and telephone
number of guardian, legal custodian or 27. Date of acknowledgment.
other person standing in loco parentis to 28. Title of person taking acknowledgement.
the child.
29. Signature of person taking
15. Guardian's, legal custodian's or person in acknowledgment.
loco parentis relationship to child.
30. Name of person filing the petition.
16. Name, street address and telephone Check appropriate title box.
number of other person involved in the
subject matter of the petition. 31. Date petition filed.
17. Check the appropriate box to show 32. If acknowledgement taken by notary
whether or not the child is in official public, provide notary’s location, date of
custody at the time of the issuance of the acknowledgement, expiration date of
petition. commission, notary’s registration
number and notary’s signature.
18. If placed in detention, give the name of
the detention or shelter care facility.

DISTRICT COURT MANUAL FORMS VOLUME

JANUARY 2009
NOTICE OF RIGHTS TO DESTRUCTION OF JUVENILE AND
DOMESTIC RELATIONS DISTRICT COURT RECORDS
(Va. Code § 16.1-306)

Records relating to a proceeding where a juvenile is found guilty of a delinquent act which would be a
felony if committed by an adult will not be destroyed.

Records related to other proceedings concerning a juvenile will be destroyed automatically when:

such juvenile is nineteen (19) years old or older and

five years have passed since the date of the last hearing in the case. However, if the juvenile was found
guilty of an offense reportable to the Virginia Department of Motor Vehicles, the records shall not be
destroyed until the juvenile is twenty-nine (29) years old.

You may request the earlier destruction of the court records in this case ONLY IF:

1. You were the subject of a delinquency or juvenile traffic proceeding, and

2. You were found innocent of the charge or the charge was otherwise dismissed, and

3. You file a motion with this court requesting destruction of the records connected with such charge
with notice being given to the Commonwealth’s Attorney.

Unless good cause is shown why the records should not be destroyed, this court shall grant the motion.

FORM DC-511 (MASTER, PAGE TWO OF TWO) 12/01

Form DC-512 NOTICE OF HEARING Form DC-512

Using This Form

1. Copies

a. Original – to court.

b. First copy – to recipient. May provide additional copies if more than one
recipient.

2. Prepared by clerk.

3. Attachments – none.

4. Preparation details

a. This form is designed to be used primarily when notice is to be hand-delivered to

the person while he or she is in court. If not hand-delivered in court, this form
may be mailed.

b. Some employers make it very difficult for employees to leave work to go to court
unless the employee is served with a subpoena or other court process. To
overcome this problem, it is suggested that this form be prepared in the courtroom
when a case is continued and a copy handed to each participant before he leaves
the courthouse. In addition to avoiding filing problems with returns of service of
process, this procedure gives the individual notice (thereby reducing the
possibility of absence due to forgetfulness). However, if the court wishes for the
participant to enter into a recognizance, district court form DC-329,
RECOGNIZANCE, should be used.

c. The form is designed so that, if mailed, it can be folded and placed in a window
envelope revealing the addressee, thereby circumventing time-consuming labeling
of each envelope.

DISTRICT COURT MANUAL FORMS VOLUME

JANUARY 2009
NOTICE OF HEARING VA. CODE §§ 16.1-252(a), 16.1-263,
16.1-282, 16.1-283, 20-60.6
3
CASE NO.

...............................................................................................................
COMMONWEALTH OF VIRGINIA
1
...............................................................................................................
NOTICE
............................................................................................................... TAKE NOTICE THAT A HEARING INVOLVING THIS CASE
WILL BE HELD AT THE ADDRESS NOTED AT LEFT ON
4 5
....................................................................... AT .............................................. M.
FOR THE PURPOSE OF:
....................................................................................................................................
2
........................................................................................................................
6
....................................................................................................................................
In re/V.
....................................................................................................................................
........................................................................................................................ ....................................................................................................................................

....................................................................................................................................

7
............................................... 8
__________________________________
DATE ISSUED [ ] CLERK [ ] DEPUTY CLERK

9 [ ] Check here if sent by mail.

10
TO:

SERVICE OF PROCESS ON PERSON TO RECEIVE NOTICE

11 [ ] PERSONAL SERVICE

[ ] Being unable to make personal service, a copy was

delivered in the following manner:
12 12 CASES TO ENFORCE CHILD SUPPORT ONLY:
[ ] Delivered to family member (not temporary sojourner or
guest) age 16 or older at usual place of abode of party [ ] Delivered to ................................................................................................. the
named above after giving information of its purport. List
name, age of recipient, and relation of recipient to party [ ] residential [ ] business address of record.
named above.
13
..............................................................................................

..............................................................................................
[ ] Posted on front door or such other door as appears to be
the main entrance of usual place of abode, address listed
above. (Other authorized recipient not found.)

14 [ ] Not found
16
SERVING OFFICER

15
............................. 17
for ___________________________
DATE

FORM DC-512 REVISED 10/08

Form DC-512 NOTICE OF HEARING Form DC-512

Data Elements

1. Court name and address.

2. Style of case.

3. Court case number.

4. Date of hearing.

5. Time of hearing.

6. Purpose of hearing.

7. Date of issuance.

8. Signature of issuing clerk or deputy clerk.

9. Check if mailed rather than served. See “Using This Form,” 4(c).

10. Person(s) to whom this notice is going. If served outside of court, include street address.

11. Check this box if served in-person on the individual identified in Data Element No. 10.

12. If not served in-person, check the appropriate box to designate type of substitute service.

13. If served by leaving the notice with a family member over age 16, insert required
information.

14. Check this box if unable to serve notice.

15. Date of service of process.

16. Signature of serving officer.

17. Jurisdiction or agency. Name of sheriff if served by deputy sheriff.

DISTRICT COURT MANUAL FORMS VOLUME

JANUARY 2009
Form DC-513 ADVISEMENT AND REQUEST Page: 1
APPOINTMENT OF COUNSEL

Using This Form

1. Copies

a. Original--to court.

b. First copy--to the juvenile.

c. Second copy--to court-appointed lawyer if one is appointed.

2. Request portion prepared by clerk or judge; order portion signed by judge.

3. Attachments

a. Form DC-511, JUVENILE PETITION

4. Preparation details

a. Data Element No. 16 is located so that this form, when completed can be folded and
inserted into a window envelope, for mailing to the attorney (if he is not in court to
receive a copy of the order of appointment). Because windows on all window envelopes
are not the same size, the clerk should experiment with a few samples to determine the
best way to use this form with the window envelope in stock.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-513 ADVISEMENT AND REQUEST FOR APPOINTMENT OF COUNSEL Page: 2
ADVISEMENT AND REQUEST FOR APPOINTMENT OF COUNSEL Case No. 1
Commonwealth of Virginia Va. Code §§ 16.1-266; 16.1-267; 19.2-159; 19.2-160

2 Juvenile and Domestic Relations District Court

In re: 3
NAME OF JUVENILE
TO THE JUVENILE:
You have the right to be represented by an attorney. You or your parent, guardian, or legal custodian may retain an attorney at your
own expense or, if it is determined by the Court that you are unable to afford an attorney and your parent, guardian or legal custodian
does not retain an attorney for you, then the Court will appoint an attorney to represent you. However, you will be presumed to be
financially unable to pay for an attorney for a detention hearing, and the court will appoint an attorney to represent you prior to a
detention hearing unless an attorney has been retained and appears on your behalf.
You may also waive your right to an attorney unless the interest of you and your parent, guardian or legal custodian are adverse;
however, if you are alleged to have committed an offense that would be a felony if committed by an adult, you may waive the right to
counsel only after consulting with an attorney and the court determines that your waiver is free and voluntary.
TO THE PARENT(S), GUARDIAN OR LEGAL CUSTODIAN:
The above-named juvenile has the right to be represented by an attorney. If the juvenile requests an attorney, then you may either
(1) retain an attorney at your own expense; or (2) request the Court to appoint an attorney. If you request a court-appointed attorney,
then you will be required to complete a financial statement to determine whether or not you are financially able to pay for the attorney.
If the Court determines after reviewing your financial statement that you are financially unable to obtain your own attorney, then an
attorney will be appointed and you will not be liable for the cost. However, if the Court decides, after reviewing your financial
statements, that you are financially able to pay for the attorney in whole or in part and you refuse to do so, then the Court will assess
you for the cost of the court-appointed attorney in whole or in part.
REQUEST FOR APPOINTMENT OF AN ATTORNEY
I have been informed this day of my right to representation by an attorney in all hearings held by the judge of this Court to consider
the case involving me. I certify that I am without means to employ an attorney and request the judge to appoint an attorney to represent
me.
4 _____________________________________________
5
DATE JUVENILE’S SIGNATURE
I certify that I am financially unable to employ an attorney and request the Court to appoint an attorney for the above-named
juvenile. My financial statement accompanies this request. I understand that if the judge appoints an attorney and finds that I have the
financial ability to pay for an attorney, then the Court will require that I pay the cost of the attorney as required by law.
6 7
_________________________________________________________ 8
_____________________________________________________
DATE PARENT OR GUARDIAN’S SIGNATURE PARENT OR GUARDIAN’S SIGNATURE

ORDER
Having examined the financial statement of the parent(s), guardian or legal custodian, as appropriate, and any other relevant evidence,
the Court finds as follows:
The juvenile is presumed to be financially unable to pay for an attorney and is entitled to a court-appointed attorney for a detention hearing.
The parent(s), guardian or legal custodian is financially able to employ an attorney at their own expense and they shall do so.
The parent(s), guardian or legal custodian is financially indigent within the guideline formula set forth in the law and the juvenile is
entitled to a court-appointed attorney, without assessment of costs.
The juvenile is entitled to a court-appointed attorney and the Court finds that the parent(s), guardian or legal custodian are financially able
9 to pay for the attorney but refuse to do so.
The interests of the juvenile and the parent(s), guardian or legal custodian are adverse and the juvenile, therefore, requires representation by an
attorney.
In the discretion of the Court, appointment of an attorney is required to represent the interests of the juvenile.
The juvenile is alleged to have committed a delinquent act that would be a felony if committed by an adult and wishes to waive the right to
counsel; therefore, appointment of an attorney is required to consult with the juvenile.
Therefore, the Court appoints the attorney indicated below for a detention hearing only to represent the juvenile at all hearings or other
10proceedings in this Court and in any other Court to which this case may be appealed or transferred until said attorney is relieved or replaced by
another attorney.
11 The above-named guardian or legal custodian is is not hereby assessed for the cost of the appointed attorney in the amount authorized by
law.
The clerk shall send a copy of this Order to the Indigent Defense Commission as notice that the attorney indicated below is not on the list
12maintained by the Commission, but has otherwise demonstrated to the Court an appropriate level of training and experience.
Name and 13
Address NEXT HEARING DATE AND TIME
of
Court- 16 14
Appointed
Attorney DATE

15
_______________________________________________________________________
JUDGE

FORM DC-513 REVISED 5/07

DISTRICT COURT FORMS FORMS VOLUME

DECEMBER 2007
Form DC-513 ADVISEMENT AND REQUEST Page: 3
APPOINTMENT OF COUNSEL

Data Elements
1. Court case number.

2. Court jurisdiction.

3. Case name (subject of petition).

4. Date on which request was signed.

5. Signature of juvenile.

6. Date on which parents or guardian signed this form.

7. Signature(s) of parent(s) or guardian.

8. Signature(s) of parent(s) or guardian.

9. Check the appropriate boxes and, if applicable,

describe special circumstances. NOTE: The court-appointed attorney fees
cannot be assessed against any juvenile.
10. Check appropriate box.

11. Check appropriate box.

12. Check box if appointed attorney is not on list maintained by the Indigent Defense
Commission (IDC).

13. Date and time of next hearing.

14. Date of entry of order.

15. Signature of judge.

16. Name and address of court-appointed lawyer, if appropriate.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-514 ORDER FOR APPOINTMENT OF Form DC-514
GUARDIAN AD LITEM

Using This Form

1. Copies

a. Original – to court.

b. First, second and third copy – to attorney appointed as guardian ad litem.

2. Prepared by clerk; signed by judge.

3. Attachments – none.

4. Preparation details

a. This form was created to address the special responsibilities of guardians ad litem
in the juvenile courts, appointed pursuant to Virginia Code § 16.1-266. General
District Courts appointing guardians ad litem pursuant to § 8.01-9 should use
form DC-401, APPOINTMENT OF GUARDIAN AD LITEM.

b. This form has been created as a four-part set with carbon paper to produce three
copies. One copy is for the guardian ad litem’s files and is marked “Attorney” at
the bottom. The other two copies are to be presented to custodians of records or
others to be interviewed by the guardian ad litem. The carbon paper has been
formatted so that the indication of the case type will not be reflected on these two
copies.

c. The last page of this snap-apart form is a copy of district court form DC-533,
ASSESSMENT/PAYMENT ORDER to be used to assess the cost of the guardian ad
litem against the parent(s) if they are able to pay. See Using This Form for the
DC-533 for instructions on how to complete this form.

d. The Standards to Govern the Performance of Guardians Ad Litem for Children

are contained on the reverse of this form.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
ORDER FOR APPOINTMENT 1
Case No. ......................................................................................
OF GUARDIAN AD LITEM
Commonwealth of Virginia VA. CODE § 16.1-266

3
In re: ...............................................................................................................................................................................
JUVENILE

4
........................................................................................................................... v.
5
...........................................................................................................................
PETITIONER RESPONDENT

This proceeding involves a Petition/Motion regarding:

[ ] custody [ ] child abuse or neglect [ ] delinquency
[ ] visitation [ ] termination of parental rights [ ] child in need of services
6 [ ] child support [ ] entrustment [ ] child in need of supervision
[ ] paternity [ ] family abuse protective order [ ] relief of custody by parent
[ ] consent to adoption [ ] other: .........................................................................................................................................................
and the Court finds that:
[ ] the juvenile named above is entitled to the appointment of a guardian ad litem pursuant to § 16.1-266 of the Code of
7 Virginia, and the best interests of the child are not adequately protected by the parties or the appointment of a
guardian ad litem is otherwise required by law.

OR
[ ] the [ ] Petitioner [ ] Respondent [ ] Defendant named above is a person under a disability and is unable to protect
8 his/her interests in this proceeding and is entitled to the appointment of a guardian ad litem pursuant to § 16.1-266 of
the Code of Virginia because of the following disability:

[ ] incarceration [ ] intellectual disability

9 [ ] mental illness [ ] minor [ ] other: ..............................................................................................................................

The Court Orders that:

10
.......................................................................................................................................................... is hereby appointed as guardian ad litem to protect
NAME OF ATTORNEY
11
and represent the interests of ............................................................................................................................. in connection with all proceedings
involved in this matter.
12
The date and time for the next hearing is: ..............................................................................................................................................................................
........................................................................................................................................................................................................................................................................

The Court further orders that the guardian ad litem perform the duties and have access to the parties and documents
specified on the reverse and incorporated by reference into this order.
So Ordered.
13
...................................................................... 14
_______________________________________________________________________________
DATE JUDGE

FORM DC-514 FRONT 07/12

Form DC-514 ORDER FOR APPOINTMENT OF Form DC-514
GUARDIAN AD LITEM

Data Elements, front

1. Court case number.

2. Jurisdiction.

3. Name of juvenile.

4. Name of petitioner.

5. Name of respondent, if applicable.

6. Check box for type of case.

7. Check if guardian ad litem appointed for a juvenile.

8. Check if guardian appointed for adult. Indicate person’s status.

9. Check the box designating the type of disability and insert the details of the disability.

10. Name of attorney appointed as guardian ad litem.

11. Name of person for whom guardian ad litem is appointed.

12. Date and time of next court hearing in the case.

13. Date of entry of order.

14. Signature of judge entering order.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
In conforming to the following standards of performance, guardians ad litem shall comply with Rule 8:6 of the Rules of
the Supreme Court of Virginia and shall be further informed of their duties and responsibilities by the commentary of the
Standards to Govern the Performance of Guardians Ad litem for Children as adopted by the Judicial Council of Virginia
effective September 1, 2003.
In fulfilling the duties of a guardian ad litem as appointed pursuant to this Order, an attorney shall:
A. Meet face to face and interview the child.
B. Conduct an independent investigation in order to ascertain the facts of the case.
C. Advise the child, in terms the child can understand, of the nature of all proceedings, the child's rights, the
role and responsibilities of the guardian ad litem, the court process and the possible consequences of the
legal action.
D. Participate, as appropriate, in pre-trial conferences, mediation and negotiations.
E. Ensure the child's attendance at all proceedings where the child's attendance is appropriate and/or mandated.
F. Appear in Court on the dates and times scheduled for hearings prepared to fully and vigorously represent
the child's interests.
G. Prepare the child to testify, when necessary and appropriate, in accord with the child's interest and welfare.
H. Provide the court sufficient information including specific recommendations for court action based on the
findings of the interviews and independent investigation.
I. Communicate, coordinate and maintain a professional working relationship, in so far as possible, with all
parties without sacrificing independence.
J. File appropriate petitions, motions, pleadings, briefs and appeals on behalf of the child and ensure that the
child is represented by a guardian ad litem in any appeal involving the case.
K. Advise the child, in terms the child can understand, of the court's decision and its consequences for the
child and others in the child's life.
Decision-making power resides with the court.
Failure to perform these duties may result in the appointing court's refusal to authorize payment of the
fees requested by the guardian ad litem or a reduction of the payment requested, removal from the assigned case
or removal from the court's Guardian Ad Litem Appointment List.
The guardian ad litem is authorized to appear at the Family Assessment and Planning Team and at panel review
hearings conducted by the local department of social services pursuant to Virginia Code § 63.2-907.
The guardian ad litem appointed to represent the child shall have access to the following persons and documents
without further Order of the Court:
A. The child.
B. Parties to the proceeding.
C. Court Appointed Special Advocate (CASA), local department of social services and court services
unit worker in the case, and school personnel involved with the child.
Upon presentation by the guardian ad litem of this order, the guardian ad litem shall have access to any
records relating to the child held by any state or local agency, department, authority or institution and any
school, hospital, physician or other health or mental health provider who shall permit the guardian ad litem to
inspect and copy such records without the consent of the child or his parents. Upon the request of a guardian ad
litem made at least seventy-two hours in advance, a mental health provider shall make himself available to
conduct a review and interpretation of the child's treatment records which are specifically related to the
investigation. Such a request may be made in lieu of or in addition to inspection and copying of the records.

FORM DC-514 REVERSE 9/03

Form DC-515 WAIVER OF RIGHT TO BE REPRESENTED Page: 1
BY A LAWYER (JUVENILE)
Using This Form

1. Copies

a. Original--to court.

b. First copy--to the juvenile.

2. Upper waiver portion of form prepared by clerk or judge and signed by juvenile and his or
her parent(s); the statement of consultation in felony cases is signed by the attorney consulted
by the juvenile and his or her parents; order and certificate portion completed and signed by
judge.

3. Attachments

Form DC-511, JUVENILE PETITION

4. Preparation details

a. This form provides a vehicle for documentary consultation with an attorney about the
consequences of waiver of a lawyer in felony cases.

b. This form also provides a vehicle for documenting consultation with an attorney about
the consequences of waiver of a lawyer in felony cases.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-515 WAIVER OF RIGHT TO BE REPRESENTED Page: 2
BY A LAWYER (JUVENILE)
WAIVER OF RIGHT TO BE REPRESENTED
BY A LAWYER (JUVENILE)
Commonwealth of Virginia Va. Code § 16.1-266 Case No. 1
...............................................................................................
2
.................................................................................................................................................................. Juvenile and Domestic Relations District Court
In re:
3
.......................................................................................................................................................................................................................................................
We have been advised by a judge, clerk or probation officer of this court of the nature of the charges in the cases pending against the
juvenile and the potential disposition of the charges, which includes (if applicable) imprisonment in the penitentiary or confinement in jail
or in a facility for juveniles. We understand the nature of these charges and the potential disposition of them if the juvenile is found to be
delinquent, in need of supervision, or in need of services.
4 [ ] The juvenile is alleged to have committed an offense that would be a felony if committed by an adult, and we understand that the
juvenile may waive the right to counsel only after consulting with an attorney and the court determines that the waiver of the right to
counsel is free and voluntary.
We have been further advised by a judge or clerk or probation officer of this court that the juvenile has the following rights to be
represented by a lawyer in these cases:
a. The juvenile has a right to be represented by a lawyer.
b. If we choose to hire a lawyer to represent the juvenile, we will be given a reasonable opportunity to hire, at our expense, a
lawyer selected by us. The judge will decide what is a reasonable opportunity to hire a lawyer. If we have not hired a lawyer
after such reasonable opportunity, the judge may try the case even though the juvenile does not have a lawyer to represent him.
c.If we ask the judge for a lawyer to represent the juvenile and the judge decides, after reviewing our sworn financial
statement(s), that we cannot afford a lawyer, the judge will select and appoint a lawyer to represent the juvenile. However, if
the juvenile or the parents are financially able to pay, the juvenile or the parents may be required to pay the lawyer’s fee as set
by the judge within statutory limits.
We understand these rights to be represented by a lawyer. We also understand that the juvenile may waive (give up) his rights to
be represented by a lawyer if the juvenile and the juvenile’s parent(s), guardian(s), legal custodian or other person standing in loco
parentis consent in writing to waiver of the right to be represented by a lawyer and the interests of the juvenile and of the juvenile’s
parent(s), guardian(s), legal custodian or other person standing in loco parentis are not adverse.
Understanding the juvenile’s rights to be represented by a lawyer as described above and further understanding the nature of the
case and the possible results if the juvenile is found to be delinquent, in need of service, or in need of supervision, we waive all of the
juvenile’s rights to be represented by a lawyer in these cases, with the further understanding that the cases will be tried without a lawyer
either being hired by us or being appointed by the judge for the juvenile. We waive these rights of our own choice, knowingly and
voluntarily, of our own free will, without any threats, promises, force or coercion.
5_________________
_____________________________
____________ 6
__________________________________ 6
__________________________________
JUVENILE PARENT OR GUARDIAN PARENT OR GUARDIAN

[ ] I have consulted with the child and parent(s) or guardian(s) on waiving the right to counsel. __________________________
ATTORNEY
ORDER
Upon oral examination, the undersigned judge of this Court finds that the juvenile and the juvenile’s parent(s), guardian(s), legal
custodian or other person standing in loco parentis having been advised of the rights and matters stated above and having understood these
rights and matters, thereafter have knowingly, voluntarily and intelligently waived the juvenile’s rights to be represented by a lawyer
[ ] after consulting with an attorney for a juvenile who is alleged to have committed an offense that would be a felony if committed by an
adult. The undersigned judge further finds that the interest of the juvenile and of the juvenile’s parent(s) guardian(s), legal custodian or
other person standing in loco parentis are not adverse.
8
....................................................................... ________________________________________________
________________________________________________
9
DATE JUDGE

CERTIFICATE OF REFUSAL
I certify that on this date, I informed the above-named juvenile of his right to be represented by a lawyer; that if because of indigency,
he cannot afford to hire a lawyer, one will be appointed by the Court; and that his refusal to sign either a request for appointment of a lawyer or a
waiver of representation by a lawyer CONSTITUTES A WAIVER OF HIS RIGHT TO REPRESENTATION BY A LAWYER.
The above-named juvenile refused to sign either a request for appointment of a lawyer or a waiver of representation by a lawyer and
did not have a privately retained lawyer. The Court shall forthwith proceed to hear and determine the case, and the above-named juvenile is
deemed to have waived representation by a lawyer.

10
........................................................................ ____________________11
____________________________
DATE JUDGE

FORM DC-515 REVISED 5/07

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-515 WAIVER OF RIGHT TO BE REPRESENTED Page: 3
BY A LAWYER (JUVENILE)
Data Elements

1. Court case number.

2. Court jurisdiction.

3. Case name (subject of petition).

4. Check this box if the juvenile is alleged to have committed a felony offense.

5. Signature of juvenile.

6. Signature(s) of parent(s) or guardian.

7. If the juvenile is alleged to have committed a felony offense, the attorney who was consulted
about the consequences of waiving the right to a lawyer must check the box and sign in the
space provided.

8. Date of entry of order.

9. Signature of judge.

10. Date of judge’s signature certifying refusal.

11. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-517 WAIVER OF JURISDICTION Page: 1

Using This Form

1. Copies — (Contact the court to determine if you should bring copies to the Clerk's Office or
if copies will be made upon filing.)

a. Original--to court file.

b. First copy--to juvenile's attorney (if counsel is employed; otherwise, to juvenile).

2. May be prepared by clerk, or by juvenile or by juvenile's attorney, signed by juvenile and

juvenile's attorney.

3. Attachments

a. Form DC-519, NOTICE OF TRANSFER HEARING

b. Form DC-511, JUVENILE PETITION/SUMMONS

c. Form DC-578, TRANSFER/RETENTION ORDER

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-517 WAIVER OF JURISDICTION Page: 2

WAIVER OF JURISDICTION Case No. . . . . . . . . . . . . . . . .1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Commonwealth of Virginia Va. Code §§ 16.1-269.1(A), -270

2
.................................................................................... Juvenile and Domestic Relations District Court

In re: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I am 14 years of age or older and have been charged with the following offenses which if committed
by an adult, would be felonies and could be punishable by confinement in a state correctional facility:

4
......................................................................................................................................................................

I understand that, pursuant to § 16.1-269.1(A), I have a right to a hearing to determine whether or

not my case should be transferred to the Circuit Court for consideration by the Grand Jury of a criminal
indictment or whether it should be adjudicated in this Court.

I have discussed my right to a transfer hearing with

5
...................................................................................., my lawyer. With his consent, I hereby voluntarily
NAME OF LAWYER

waive my rights to such a hearing and waive this Court’s jurisdiction over my case.

I request that this court transfer my case to the Circuit Court of

6
..........................................................................................,there to be dealt with in the same manner as if it had
NAME OF CITY/COUNTY

been transferred pursuant to Va. Code §§ 16.1-269.1 to –269.6.

7
................................................ ______________________________________________
8
DATE JUVENILE’S SIGNATURE

I, the above-named lawyer, have discussed this waiver with my client and hereby agree and
consent to his waiver.

9
______________________________________________
LAWYER’S SIGNATURE

FORM DC-517 (MASTER) REVISED 10/07

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-517 WAIVER OF JURISDICTION Page: 3

Data Elements

1. Court case number.

2. Court name.

3. Case name (name of subject of petition).

4. Description of offenses allegedly committed by juvenile.

5. Lawyer representing the juvenile.

6. Name of circuit court to which this case would be transferred.

7. Date of signing of waiver.

8. Signature of juvenile defendant.

9. Signature of attorney for defendant.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-518 TRANSFER/RETENTION ORDER Form DC-518

Using This Form

1. Copies

a. Original – for court case file.

b. Copies as determined by local practice.

2. Prepared by clerk; signed by judge. Can be prepared by judge on the bench.

3. Attachments

a. Form DC-519, NOTICE OF TRANSFER HEARING.

b. Form DC-510, JUVENILE SUMMONS.

c. Form DC-517, WAIVER OF JURISDICTION.

4. Preparation details – This form is designed for ease of preparation in the courtroom while
stating the statutory provisions in detail if transfer is ordered.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
TRANSFER/RETENTION ORDER
COMMONWEALTH OF VIRGINIA VA. CODE ANN. § 16.1-269.1 (A) 1
CASE NO.: ...................................................
2
...................................................................................................................................................................... Juvenile and Domestic Relations District Court

3
In re: .............................................................................................................................................................................................................................................................

Present: [ ] Juvenile [ ] Mother .................................................................................. [ ] Father ................................................................................................

4 [ ] Attorney for Juvenile .............................................. [ ] Commonwealth’s Attorney ..................................................... [ ] Other..................................
The above-named juvenile is within the jurisdiction of this Court by reasons of a verified petition filed against the juvenile in this cause,
alleging the commission of an offense, namely:
5
..............................................................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................................................
Which if committed by an adult would be a felony, punishable by confinement in a state correctional facility.
6 [ ] Pursuant to Virginia Code § 16.1-270, the above-named juvenile, with consent of counsel, waived in writing the jurisdiction of the
Juvenile and Domestic Relations District Court. (Executed Waiver of Jurisdiction attached.)
7 [ ] In compliance with the Code of Virginia and on motion of the Commonwealth’s Attorney, a transfer hearing was conducted
following proper notice pursuant to Va. Code §§ 16.1-263 and 16.1-264 having been given to the juvenile, the juvenile’s
parents, guardian, legal custodian or other person standing in loco parentis or attorney.
8 [ ] Prior to this transfer hearing, a written study report to the court was prepared by the probation services or other qualified agency
designated by the Court as required by the Code of Virginia; this report and study together with any other data and reports concerning
the juvenile which were available to the Court were also made available to counsel for the juvenile.
9 [ ] The Commonwealth withdraws the motion to transfer.
[ ] The Court finds from the evidence presented that there is probable cause to believe the juvenile committed the
[ ] delinquent act(s) alleged.
10 [ ] following lesser-included delinquent acts
.............................................................................................................................................................................................................................................................
11 [ ] The Court finds that the evidence is insufficient to establish probable cause to believe that the juvenile committed the alleged
delinquent act, and therefore the case is dismissed.

From the evidence and upon consideration of the study and report (which was not considered until the finding concerning probable cause
was made), the Court finds:
[ ] That the juvenile was fourteen or more years of age at the time of the alleged commission of the offense; the juvenile is competent to
12 stand trial; and the juvenile is not a proper person to remain in the juvenile court.
[ ] the statutory factors in § 16.1-269.1 (A)(4) have been considered. (See reverse)
13 [ ] That the requirements for transfer have not been satisfied.
The Court
[ ] Hereby RETAINS jurisdiction of the charge against the juvenile.
[ ] TRANSFERS and so certifies the juvenile for proper criminal proceedings to the Circuit Court of
14 ........................................................................................................................... Virginia, which court of record has jurisdiction of this offense and
that the juvenile was notified of his right to appeal this decision.

The Court further orders that the juvenile be:

[ ] Remanded to jail [ ] ...........................................................................................................................................................................................................................
[ ] Detained in the .......................................................................................................................................................................................................................................
NAME OF DETENTION FACILITY
15 [ ] Released into the care and custody of the juvenile’s parent(s), guardian, or person standing in loco parentis.
[ ] Bail is set in the amount of $............................................................ [ ] Continued bail in the amount of $ ....................................................................

16
....................................................................................................................................... 17
____________________________________________________________
DATE JUDGE

FORM DC-518 (MASTER, PAGE ONE OF TWO) 12/03

Form DC-518 TRANSFER/RETENTION ORDER Form DC-518

Data Elements, page one

1. Court case number.

2. Court name.

3. Juvenile’s name.

4. Check appropriate boxes indicating those present at the hearing and insert names.

5. Description of offense(s).

6. Check box if juvenile waived jurisdiction of juvenile and domestic relations district court.

7. Check box if transfer hearing held.

8. Check box if report prepared.

9. Check box if the motion to transfer withdrawn.

10. If probable cause is found, check the appropriate box and, if applicable, insert a
description of the lesser-included offense.

11. If probable cause is not found, check this box.

12. If probable cause was found (Data Element No. 10) and if the court finds that the
requirements for transfer have been met, check the first box and either the second or third
box to show the court's findings that the transfer requirements were met.

13. If probable cause was found (Data Element No. 10) but the court found that the
requirements for transfer have not been met, check this box.

14. Check the appropriate box; if transferred, add the name of the court to which the case is
transferred.

15. Check the appropriate interim disposition box and fill in the appropriate blanks.

16. Date of entry of order.

17. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
In determining whether a juvenile is a proper person to remain within the jurisdiction of the juvenile court, the court shall
consider, but not be limited to, the following factors:
a. The juvenile’s age;
b. The seriousness and number of alleged offenses, including (i) whether the alleged offense was committed in an aggressive,
violent, premeditated or willful manner; (ii) whether the alleged offense was against persons or property, with greater weight being given
to offenses against persons, especially if death or bodily injury resulted; (iii) whether the maximum punishment for such an offense is
greater than twenty years confinement if committed by an adult; (iv) whether the alleged offense involved the use of a firearm or other
dangerous weapon by brandishing, threatening, displaying or otherwise employing such weapon; and (v) the nature of the juvenile’s
participation in the alleged offense;
c. Whether the juvenile can be retained in the juvenile justice system long enough for effective treatment and rehabilitation;
d. The appropriateness and availability of the services and dispositional alternatives in both the criminal justice and juvenile
justice systems for dealing with the juvenile’s problems;
e. The record and previous history of the juvenile in this or other jurisdictions, including (i) the number and nature of previous
contacts with juvenile or circuit courts, (ii) the number and nature of prior periods of probation, (iii) the number and nature of prior
commitments to learning centers, (iv) the number and nature of previous residential and community-based treatments, (v) whether
previous adjudications and commitments were for delinquent acts that involved the infliction of serious bodily injury, and (vi) whether the
alleged offense is part of a repetitive pattern of similar adjudicated offenses;
f. Whether the juvenile has previously absconded from the legal custody of a juvenile correctional entity in this or any other
jurisdiction;
g. The extent, if any, of the juvenile’s degree of intellectual disability or mental illness;
h. The juvenile’s school record and education;
i. The juvenile’s mental and emotional maturity; and
j. The juvenile’s physical condition and physical maturity.

Reasons for decision ....................................................................................................................................................................................................................................

1
..............................................................................................................................................................................................................................................................................

2
.............................................................................................. 3
__________________________________________________________________
DATE JUDGE

FORM DC-518 (MASTER, PAGE TWO OF TWO) 07/12

Form DC-518 TRANSFER/RETENTION ORDER Form DC-518

Data Elements, page two

1. Insert the reasons for the decision.

2. Date order issued.

3. Judge's signature.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
Form DC-519 NOTICE OF TRANSFER HEARING Form DC-519

Using This Form

1. Copies

a. Original – to court.

b. Additional copies to each person required to receive notice.

2. Prepared by clerk.

3. Attachments

District court form DC-511, JUVENILE PETITION/SUMMONS – a copy of this form is

attached to each copy of the NOTICE OF TRANSFER HEARING, if issued at the same
time.

4. Preparation details

The return on the back of this Notice does not have to be executed if this Notice is
prepared and attached to all copies of the JUVENILE PETITION/SUMMONS, district court
form DC-511, prior to the service of the Petition. Otherwise, this Notice shall be
served in the same manner as the Petition.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 1997
NOTICE OF TRANSFER HEARING 1
Case No. ..............................................................................................
COMMONWEALTH OF VIRGINIA VA. CODE ANN. §§ 16.1-263, 16.1-264, 16.1-269.1(A)

2
................................................................................................................................................................................................................................... Juvenile and Domestic Relations District Court
CITY OR COUNTY

3
Commonwealth v. ..............................................................................................................................................................................................................................................................................................................

TO: (Juvenile and parent, guardian, legal custodian or other person standing in loco parentis; or attorney)

You are NOTIFIED pursuant to §§ 16.1-263, 16.1-264, and 16.1-269.1(A) of the Code of Virginia that a hearing will be held on

5
............................................................................................................................................................................................................................................... at 6
...................................................................................... p.m.
to determine whether the charges described below in this Notice or in the attached Petition against the juvenile named above shall be
transferred to the Circuit Court for criminal proceedings or shall be retained for further proceedings by this Court.

This court has ordered the preparation of a study and report by the probation services, or other qualified agency designated by the
Court. This written report will be submitted to the Court prior to the date set for the transfer hearing and made available to the lawyer
for the juvenile and the attorney for the Commonwealth at the transfer hearing.

Charges ...........................................................................................................................................................................................................................................................................................................

7 ...........................................................................................................................................................................................................................................................................................................

Petition attached

8
................................................................................... 9
_______________________________________________________________________________
DATE CLERK

FORM DC-519 (MASTER, PAGE ONE OF TWO) 5/96

Form DC-519 NOTICE OF TRANSFER HEARING Form DC-519

Data Elements, page one

1. Court case number.

2. Court name.

3. Name of juvenile.

4. Name of person(s) who are to receive this Notice.

5. Date of hearing.

6. Time of hearing.

7. If form DC-511, JUVENILE PETITION/SUMMONS, is attached, check appropriate box.

Otherwise, list charges which are the subject of a transfer hearing.

8. Date of issuance of Notice.

9. Signature of clerk issuing this Notice.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 1997
EXECUTED by delivering a true copy of this notice to the
person named below this day. 2
..............................................................
DATE

1
.............................................................................................. 3 SERVING
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OFFICER

.............................................................................................. 4
____________________________________________________________
BADGE NO., AGENCY AND JURISDICTION
..............................................................................................
for _________________________________________________________ 5
SHERIFF

EXECUTED by delivering a true copy of this notice to the

person named below this day. ..............................................................
DATE

SERVING
.............................................................................................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OFFICER

.............................................................................................. ____________________________________________________________
BADGE NO., AGENCY AND JURISDICTION
..............................................................................................
for _________________________________________________________
SHERIFF

FORM DC-519 (MASTER, PAGE TWO OF TWO) 1/81

Form DC-519 NOTICE OF TRANSFER HEARING Form DC-519

Data Elements, page two

1. Name of person(s) served (to be completed by serving officer).

2. Date of service of process.

3. Signature of serving officer.

4. Badge number, agency, and name of jurisdiction employing serving officer.

5. If served by a deputy sheriff, print or type name of sheriff.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 1997
Form DC-521 WAIVER OF PRELIMINARY HEARING Page: 1
AND CERTIFICATION

Using This Form

This form has been created for use when a juvenile is charged with a felony where the
juvenile court has jurisdiction to conduct a preliminary hearing pursuant to Virginia
Code § 16.1-269.1(B) or (C). The juvenile may waive his right to a preliminary hearing and
request that the juvenile court certify the felony charge, and any ancillary charges, to the circuit
court of the jurisdiction.

1. Copies — (Contact the court to determine if you should bring copies to the Clerk's Office or
if copies will be made upon filing.)

a. Original — to court.

b. First copy — to defendant (juvenile).

2. Prepared by defendant (juvenile) and counsel; signed by judge.

3. Attachments — form DC-511 JUVENILE PETITION for charges involved in the waiver.

4. Preparation Details — none.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-521 WAIVER OF PRELIMINARY HEARING Page: 2
AND CERTIFICATION

WAIVER OF PRELIMINARY HEARING 1

Case No. ......................................................................
AND CERTIFICATION
Commonwealth of Virginia VA. CODE § 16.1-269.1(B) & (C)

2
................................................................................................................................. Juvenile and Domestic Relations District Court

I am fourteen years of age or older and have been charged with the following offenses which if committed by an
adult, would be felonies and could be punishable by confinement in a state correctional facility:

I understand that I have the right to a preliminary hearing before the Court named above to determine whether
there is probable cause to believe that I committed a felony AND having the consequences of my waiver explained
to me by the Judge of this Court, I nevertheless WAIVE MY RIGHT TO A PRELIMINARY HEARING on the
felony offenses named above.

5
........................................................................ _____________________________________________________________________6
DATE JUVENILE’S SIGNATURE

7
_____________________________________________________________________
ATTORNEY FOR THE JUVENILE

ORDER

8 [ ] The above-named felony offenses

9 [ ] and the following ancillary charges: ........................................................................................................................................................
..................................................................................................................................................................................................................................
are ORDERED certified to the grand jury of the Circuit Court of this jurisdiction.

The Court further ORDERS that the juvenile be:

10 [ ] Remanded to jail. [ ] .........................................................................................................................................................................

[ ] Released into the care and custody of the juvenile’s parent(s), guardian or person standing in loco parentis.
[ ] Bail is set in the amount of $ ..................................... [ ] Continued on bail in the amount of $ ...................................

[ ] Detained in the .......................................................................................................................................................... detention facility.

11
........................................................................ 12
______________________________________________________________
DATE JUDGE

FORM DC-521 MASTER 4/97

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-521 WAIVER OF PRELIMINARY HEARING Page: 3
AND CERTIFICATION

Data Elements

1. Court case number.

2. Jurisdiction.

3. Juvenile's name.

4. Description of the charge(s) involved, including Virginia Code section.

5. Date of waiver.

6. Signature of juvenile.

7. Signature of counsel for the juvenile.

8. Check box if certifying charge(s) named in Data Element 4.

9. Check box if certifying ancillary charges in addition to charge(s) in Data Element 4.

Describe the ancillary charges, including Virginia Code section.

10. Check appropriate boxes showing juvenile's status after certification. Describe amount of bail
or place of detention if applicable.

11. Date order of certification entered.

12. Judge's signature.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-522 ORDER FOR EVALUATION TO DETERMINE Form DC-522
COMPETENCY TO STAND TRIAL – JUVENILE

Using This Form

1. Copies

a. Original – to court.

b. First copy – to evaluator(s) or hospital.

c. Second copy – to juvenile’s lawyer.

d. Third copy – to Commonwealth’s Attorney.

2. Prepared by clerk, signed by judge.

3. Attachments – form DC-354, CUSTODIAL TRANSPORTATION ORDER (only if inpatient

treatment ordered).

4. Preparation details

Inpatient evaluation should be ordered only if the juvenile is already hospitalized or a

previous competency evaluation indicates that it is necessary.

DISTRICT COURT MANUAL FORMS MANUAL

JULY 2009
ORDER FOR EVALUATION Case No. 1
........................................................................................
TO DETERMINE COMPETENCY TO
STAND TRIAL – JUVENILE
Commonwealth of Virginia VA. CODE § 16.1-356

2
............................................................................................................................................................................... Juvenile and Domestic Relations District Court
3
...............................................................................................................................................................................................................................................................................
COURT ADDRESS

In re: ............................................................................................................................................................................................................................................ , a juvenile

4
It appearing to the Court, on motion of [ ] Commonwealth’s attorney [ ] juvenile’s attorney [ ] the Court and upon hearing
evidence or representations of counsel, that there is probable cause to believe that the juvenile lacks substantial capacity to understand
the proceedings against him or her or to assist in his or her own defense, the Court therefore appoints the evaluator(s) listed below,
who is qualified by training and experience in the forensic evaluation of juveniles, to evaluate the juvenile and to submit a report,
5
and to submit a report, on or before .................................................................................... , to this Court, the Commonwealth’s Attorney and
DATE AND TIME
the juvenile’s attorney, concerning:

(1) the juvenile’s capacity to understand the proceedings against him or her;
(2) his or her ability to assist his or her attorney; and
(3) his or her need for services in the event that he or she is found to be incompetent including a description of the suggested
necessary services and least restrictive setting to assist the juvenile in restoration to competency.

No statements of the juvenile relating to the alleged offense shall be included in the report.

DESIGNATION OF EVALUATOR(S)
6[ ] The Court finds that the evaluation must be conducted on an outpatient basis at a community services board or behavioral health
authority, juvenile detention home or juvenile justice facility.
The Court therefore ORDERS the following evaluator(s) to conduct the evaluation:
7
......................................................................................................................................................................................................................................................................
OUTPATIENT EVALUATOR(S): NAME(S) AND TITLE(S) OR NAME OF FACILITY

8[ ] The Court finds that the evaluation must be conducted on an inpatient basis because:
[ ] the juvenile is currently hospitalized in a psychiatric hospital.
The court therefore ORDERS that qualified staff, trained and experienced in the forensic evaluation of juveniles, in that
psychiatric hospital conduct the evaluation.
[ ] the results of the outpatient competency evaluation (copy attached) indicate that hospitalization for evaluation of competency
is necessary.
The Court therefore ORDERS that qualified staff, trained and experienced in the forensic evaluation of juveniles, at a
hospital to be designated by the Commissioner of the Department of Behavioral Health and Developmental Services or his or
her designee conduct the evaluation. The Commissioner shall arrange for admission to such hospital only after the required
information is received from the attorneys. Hospitalization for evaluation shall not extend beyond 10 days from the date of
admission.

The Court further orders the Commonwealth’s Attorney and the attorney for the juvenile to forward information relevant to the
evaluation, as required by statute (see reverse) and orders the moving party to provide a summary of the reasons for the
9
evaluation request, to the evaluator(s) by ......................................................................... at .................................... m.
DATE TIME

TO EVALUATORS AND ATTORNEYS: See reverse for additional instructions.

10
........................................................... at .......................................... m. 11
______________________________________________________________
DATE TIME JUDGE

FORM DC-522 (MASTER, PAGE ONE OF TWO) 07/09

Form DC-522 ORDER FOR EVALUATION TO DETERMINE Form DC-522
COMPETENCY TO STAND TRIAL – JUVENILE

Data Elements

1. Court case number.

2. Court name and address.

3. Name of juvenile.

4. Check the appropriate box to indicate on whose motion the order is being entered.

5. Date and time that evaluation reports must be received by court.

6. Check this box if the evaluation is to be performed on an outpatient basis.

7. Insert name of the outpatient evaluator(s).

8. Check this box if the evaluation is to be performed on an inpatient basis, then check the
appropriate reason for ordering an evaluation on an inpatient basis.

9. Insert date and time by which the Commonwealth’s Attorney and the juvenile’s attorney
must forward information to the evaluator. This date and time should be no more than 96
hours after the order is issued. If the 96 hours ends on a weekend or holiday, the time
shall be extended to the next business day.

10. Date and time of entry of order.

11. Signature of judge.

DISTRICT COURT MANUAL FORMS MANUAL

JULY 2009
ADDITIONAL INSTRUCTIONS TO EVALUATOR(S) AND ATTORNEYS

Providing Background Information

Prior to an evaluation of competency to stand trial, the Commonwealth’s Attorney shall provide the
evaluator(s):

a. a copy of the warrant or petition

b. the names and address of the Commonwealth’s Attorney, the juvenile’s attorney, and the judge
ordering the evaluation
c. Information about the alleged offense
d. any other relevant information

The attorney for the juvenile shall provide to the evaluator only those psychiatric records of the juvenile and
other information that are deemed relevant to the evaluation of competency.

Use of Information Obtained During Evaluation

No statement or disclosure by the juvenile relating to the alleged offense made during the
competency evaluation may be used against a juvenile at the adjudication or disposition as evidence or as a
basis for such evidence. Virginia Code §§ 16.1-356, 16.1-360.

FORM DC-522 (MASTER, PAGE TWO OF TWO) 7/99

Form DC-523 ORDER FOR PROVISION OF RESTORATION Form DC-523
SERVICES TO INCOMPETENT JUVENILE

Using This Form

1. This form is used to order provision of service to a juvenile who has been found
incompetent following evaluation.

2. Copies
a. Original – to court.

b. First copy – to the Department of Behavioral Health and Developmental Services.

c. Second copy – to Commonwealth’s Attorney.

d. Third copy – juvenile’s attorney.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2009
ORDER FOR PROVISION OF RESTORATION Case No. 1
........................................................................................
SERVICES TO INCOMPETENT JUVENILE
Commonwealth of Virginia VA. CODE §§ 16.1-357; 16.1-358

2
............................................................................................................................................ Juvenile and Domestic Relations District Court
2
.................................................................................................................................................................................................................................................................
COURT ADDRESS

The Court having found, pursuant to Virginia Code § 16.1-356(F), that the juvenile is incompetent to stand trial,
and having found further, based on the attached report or other evidence, that the juvenile can be provided
services to restore his or her competency in

[ ] a non-secure community setting

4
[ ] a secure facility as defined in Virginia Code § 16.1-228

the Court therefore ORDERS that the Commissioner of Behavioral Health and Developmental Services or his
or her designee shall arrange for the provision of restoration services to the juvenile in an effort to restore him
or her to competency.

If, at any time after the provision of restoration services commences, the agent providing restoration believes
the juvenile’s competency is restored, the agent shall immediately send a report to the court concerning (1) the
juvenile’s capacity to understand the proceedings against him or her and (2) his or her ability to assist his or her
attorney.

If, at any time after the provision of restoration services commences, the agent providing restoration concludes
that the juvenile is likely to remain incompetent for the foreseeable future, the agent shall send a report to the
court so stating and indicating whether, in the agent’s opinion, the juvenile should be (1) released; (2) provided
other services by the court; (3) committed in accordance with the applicable provisions of Article 16 (§ 16.1-
335 et seq.) of Chapter 11 of Title 16.1, or, if the juvenile has reached the age of eighteen (18) at the time of the
competency determination, pursuant to Article 5 (§ 37.2-814 et seq.) of Chapter 8 of Title 37.2; or (4) certified
pursuant to § 37.2-806 of the Code of Virginia.

If the juvenile has not been restored to competency by three (3) months from the date of the commencement of
the provision of restoration services, the agent providing restoration shall send a report to the court so stating
and indicating whether, in the agent’s opinion, the juvenile remains restorable to competency or whether the
juvenile should be (1) released; (2) provided other services by the court; (3) committed pursuant to Article 16 (§
16.1-335 et seq.) of Chapter 11 of Title 16.1, or, if the juvenile has reached the age of eighteen (18) at the time
of the competency determination, pursuant to Article 5 (§ 37.2-814 et seq.) of Chapter 8 of Title 37.2; or (4)
certified pursuant to § 37.2-806 of the Code of Virginia.
5
A review hearing is set for ................................................................................................. .
DATE AND TIME

6
.............................................................. 7
_______________________________________________
DATE JUDGE

NOTICE: No statement or disclosure by the juvenile relating to the alleged offense made during the provision
of services to restore competency may be used against the juvenile at the adjudication or disposition as evidence
or as a basis for such evidence. Va. Code § 16.1-360.

FORM DC-523 MASTER 07/09

Form DC-523 ORDER FOR PROVISION OF RESTORATION Form DC-523
SERVICES TO INCOMPETENT JUVENILE

Data Elements

1. Court case number.

2. Court name and address.

3. Name of juvenile.

4. Check appropriate box as to whether the juvenile will be provided services in a non-
secure or secure setting.

5. Date and time of review hearing.

6. Date of entry order.

7. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2009
Form DC-524 NOTICE OF RIGHT TO Form DC-524
CONSIDERATION OF DIVERSION

Using This Form

1. Copies

a. Original – to court.

b. First copy – to juvenile.

c. Second copy – to law enforcement officer.

2. Attachments

a. Summons

3. Preparation details

a. This form is required to be served on the juvenile at the time that a summons
charging a violation of Va. Code § 18.2-250.1 is served on the juvenile.

b. Data Element Nos. 1 through 9 prepared and signed by the law enforcement
officer. Data Element Nos. 10 through 17 prepared and signed by the juvenile
and the juvenile’s parent/legal guardian, attorney or guardian ad litem if the
juvenile elects to have the charge referred to the Court Services Unit for
consideration of informal proceedings pursuant to Va. Code § 16.1-260(B).

DISTRICT COURT MANUAL FORMS VOLUME

JANUARY 2012
NOTICE OF RIGHT TO 1
Case No. .............................................................................
CONSIDERATION OF DIVERSION
Commonwealth of Virginia Va. Code § 16.1-260(B), (H)(3)

2
.......................................................................................................................... Juvenile and Domestic Relations District Court

4
In re: .........................................................................................................................................................................................................................................

5
......................................................................................................... 6
.........................................................................................................
OFFENSE DATE TRIAL DATE

The juvenile named above, having been charged with a violation of Virginia Code § 18.2-250.1, is
entitled to have the charge referred to the Court Services Unit of the juvenile and domestic relations district court
having jurisdiction over this charge for consideration of informal proceedings pursuant to subsection B of § 16.1-
260. This right must be exercised by written notification to the clerk of the juvenile and domestic relations
district court not later than ten (10) days prior to the date set for trial.

I affirm that I served this Notice in person on the juvenile named above, along with the summons
charging the offense noted above.

7
.................................................... 8
___________________________________________ 9
.......................................................................................
DATE SERVING OFFICER LAW ENFORCEMENT AGENCY

NOTIFICATION FOR REFERRAL

OF CHARGE TO COURT SERVICES UNIT

Having been advised of the right to have the Court Services Unit of this court consider the above charge
for informal proceedings pursuant to subsection B of § 16.1-260, the clerk of this court is so notified that the
juvenile elects to have this charge referred to the Court Services Unit.

10
.................................................... 11
....................................................................................... 12
___________________________________________
DATE NAME OF JUVENILE SIGNATURE

13
......................................................................................................................................................................................................................................................
ADDRESS AND TELEPHONE NUMBER OF JUVENILE

14
.................................................... 15
....................................................................................... 16
___________________________________________
DATE NAME OF [ ] PARENT/LEGAL GUARDIAN SIGNATURE
[ ] COUNSEL
[ ] GUARDIAN AD LITEM

FORM DC-524 REVISED 10/11

Form DC-524 NOTICE OF RIGHT TO Form DC-524
CONSIDERATION OF DIVERSION

Data Elements

1. Court case number.

2. Name of court.

3. Address of court.

4. Name of juvenile.

5. Date offense occurred.

6. Date of trial.

7. Date signed by serving officer.

8. Signature of serving officer.

9. Law enforcement agency of serving officer.

10. Date of signature of juvenile.

11. Print name of juvenile.

12. Signature of juvenile.

13. Address and telephone number of juvenile named in Data Element No. 11.

14. Date of signature of parent/legal guardian, counsel, or guardian ad litem.

15. Print name of parent/legal guardian, counsel, or guardian ad litem. Check appropriate
box below signature line.

16. Signature of person named in Data Element No. 15.

17. Address and telephone number of adult named in Data Element No. 15.

DISTRICT COURT MANUAL FORMS VOLUME

JANUARY 2012
Form DC-527 PRELIMINARY CHILD PROTECTIVE ORDER – Form DC-527
ABUSE AND NEGLECT

Using This Form

1. Copies

a. Original – to court.

b. Copy – to parent or other person named in Data Element No. 6.

c. Copy – to parent if different from individual referred to in b., above.

d. Copy – to investigatory entity named in paragraph number 3 on page one of form.

e. Copy – to person protected by order.

f. Copy – to family member of protected person.

g. Copy – to the local law enforcement agency for service of process.

h. Prepared by clerk, signed by judge.

2. Attachments

a. Form DC-510, SUMMONS, if issued when the PRELIMINARY CHILD PROTECTIVE ORDER is
entered.

b. Form DC-621, NON-DISCLOSURE ADDENDUM, for person age 12 or older who is protected by
the order, a family member of the protected person and others as appropriate.

c. Form DC-511, JUVENILE PETITION; adult criminal warrant; or written motion, if any.

d. Form DC-547, SUPPLEMENTAL SHEET TO CHILD PROTECTIVE ORDER, if used.

e. AFFIDAVIT (if used).

3. Preparation details

a. This form does not have to be used with any other preprinted form; however, the affidavit
should be attached only to the original order if an affidavit is used in the ex parte
proceeding.

b. This form can accommodate two respondents where the conditions are the same and the same
child is being protected.

c. With page two, complete form DC-621, NON-DISCLOSURE ADDENDUM, for the person age
12 or older who is protected by the order, the family member of the protected person and, as
appropriate, for the petitioner and any other person whose address information should not be
disclosed.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
PRELIMINARY CHILD PROTECTIVE ORDER – 1
Juvenile Case No. ....................................................................
ABUSE AND NEGLECT
Commonwealth of Virginia Va. Code § 16.1-253
2
.........................................................................................................
DATE OF HEARING
3
............................................................................................................................................ Juvenile and Domestic Relations District Court

4
In re: ................................................................................................................................. 5
.........................................................................................................
NAME OF CHILD DATE OF BIRTH
Present:
[ ] Mother .............................................................................................. [ ] Mother’s attorney ..........................................................................................
[ ] Father ................................................................................................ [ ] Father’s attorney ............................................................................................
6
[ ] Child .................................................................................................. [ ] Guardian ad litem ..........................................................................................
[ ] Agency Representative .................................................................. [ ] Agency attorney ............................................................................................
[ ] Other ................................................................................................. [ ] CASA ..............................................................................................................
COMPLETE DATA BELOW IF KNOWN COMPLETE DATA BELOW IF KNOWN
DESCRIPTION OF PERSON (No. 1) SUBJECT TO THIS ORDER DESCRIPTION OF PERSON (No. 2) SUBJECT TO THIS ORDER

NAME: NAME:
RACE SEX BORN HT. WGT. EYES HAIR RACE SEX BORN HT. WGT. EYES HAIR
MO. DAY YR. FT. IN. MO. DAY YR. FT. IN.

SSN SSN

7 7
It appearing that the above-named child is within the purview of the Juvenile and Domestic Relations District Court law, and upon
8[ ] a petition of [ ] a motion of ..................................................................................................................................... or [ ] the Court’s own motion,
9[ ] In an ex parte proceeding, based on a petition/motion supported by [ ] an affidavit [ ] sworn testimony before the judge or intake officer, it is
established the child may be subject to an imminent threat to life or health to the extent that delay for the provision of an adversary hearing
would be likely to result in serious or irremediable injury to the child’s life or health.
OR 10
11 [ ] After an adversary hearing following notice given in a manner prescribed by law, the court finds it necessary to protect the child’s life, health,
safety or normal development pending the final determination of a matter before the court.
THEREFORE, the Court orders that:

12 12
LAST FIRST MIDDLE LAST FIRST MIDDLE
NAME OF PERSON (NO.1) SUBJECT TO ORDER NAME OF PERSON (NO. 2) SUBJECT TO ORDER
(PARENT, GUARDIAN, LEGAL CUSTODIAN OR OTHER FAMILY OR HOUSEHOLD MEMBER) (PARENT, GUARDIAN, LEGAL CUSTODIAN OR OTHER FAMILY OR HOUSEHOLD MEMBER)

is/are required to observe reasonable conditions of behavior as set forth below:

FORM DC-527 (MASTER, PAGE ONE OF _____) 07/13 14

Form DC-527 PRELIMINARY CHILD PROTECTIVE ORDER – Form DC-527
ABUSE AND NEGLECT

Data Elements, page one

1. Court case number.

2. Insert date of hearing at which this order is entered.

3. Insert court name.

4. Insert case name (name of child who is the subject of a petition or motion).

5. Insert child’s date of birth.

6. Check boxes and fill in name of persons present for the hearing.

7. Insert identifying information for person(s) to whom this order is directed.

8. Check applicable box and insert name of petitioner or moving party, if applicable.

9. Check this box if this order was issued after an ex parte hearing.

10. If Data Element No. 8 is checked, check the appropriate box to show what type of
supporting evidence was presented.

11. Check this box if this order was issued after an adversary hearing.

12. Name(s) of person(s) who is(are) the subject of this order.

13. Check box(es) and complete condition(s) of behavior imposed by the judge.

14. Enter total number of pages of this order.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
1
Case No. ........................................................................................................
[ ] 8. 2
......................................................................................................................................................................................................................................................
......................................................................................................................................................................................................................................................
......................................................................................................................................................................................................................................................

3[ ] 3
Supplemental Sheet to Child Protective Order, DC-547, attached and incorporated by reference. No. of supplemental pages: ..........

4
[ ] Ex Parte Proceedings Only: It is further ORDERED that a preliminary protective order hearing be held at the court
on ............................................................................................................................................... at ............................................................................... and
that the parents, guardian, legal custodian, other person standing in loco parentis to the child, the family or household member
named above, and the child if he or she is 12 years of age or older be given notice of this hearing.
5
[ ] No affidavit filed. The basis upon which this order is entered, including a summary of the allegations made and the Court’s
findings is ....................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................................
5
.........................................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................................

6
The specific factual circumstances necessitating the issuance of this order are: ..............................................................................................................
........................................................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................................................

ADJUDICATION OF PETITIONS ALLEGING ABUSE OR NEGLECT OR AT RISK OF ABUSE OR NEGLECT

[ ] The Court finds, by preponderance of the evidence, that:
[ ] the child is abused or neglected.
7
[ ] the child is at risk of being abused or neglected by a parent or custodian who has been adjudicated as having abused or
neglected another child in the care of the parent or custodian.
8[ ] 8
An objection having been made by ....................................................................................................................................................................................
pursuant to Virginia Code § 16.1-253 F to the Court’s entering a finding with respect to the allegation of abuse or neglect,
9
an ajudicatory hearing is set for ........................................................................ at ..................................... . This ORDER shall remain
in full force and effect pending the adjudicatory hearing.

10
A dispositional hearing shall be held pursuant to Virginia Code § 16.1-278.2 on ........................................................ at ............................

WARNINGS TO THE PERSON(S) SUBJECT TO THIS ORDER:

Pursuant to Virginia Code § 18.2-308.1:4, you are prohibited from the purchase or transport of any firearm while this order is in effect.
If you have a concealed handgun permit, you must immediately surrender that permit to the court entering this order. If you violate the
conditions of this order, you may be sentenced to jail and/or ordered to pay a fine.
This order will be entered into the Virginia Criminal Information Network. A motion may be filed with the court at any time
requesting a hearing to dissolve or modify this order. However, this order remains in full force and effect unless and until a
subsequent order or the dispositional order is entered by the Court. Only the Court can change this order.
FULL FAITH AND CREDIT: If this order was issued after an adversarial hearing, this order shall be enforced, even without
registration, by the courts of any state, the District of Columbia, and any U.S. Territory, and may be enforced on Tribal Lands
(18 U.S.C. § 2265).
FEDERAL OFFENSES: Crossing state, territorial, or tribal boundaries to violate this order may result in federal imprisonment
(18 U.S.C. § 2262). Federal law provides penalties for possessing, transporting, shipping or receiving any firearm or ammunition
while subject to a qualifying protective order and under the circumstances specified in 18 U.S.C. § 922(g)(8).

11 [ ] 11
This ORDER is set for review on .................................................................................................... at ..............................................
DATE TIME

12
....................................................................................... 13
_____________________________________________________________
DATE JUDGE

FORM DC-527 (MASTER, PAGE TWO OF _____) 07/14

Form DC-527 PRELIMINARY CHILD PROTECTIVE ORDER – Form DC-527
ABUSE AND NEGLECT

Data Elements, page two

1. Insert court case number.

2. Check box, if applicable, and insert other orders of the Court.

3. Check box if a SUPPLEMENTAL SHEET TO CHILD PROTECTIVE ORDER is attached and

insert number of supplemental pages.

4. If this order is issued after an ex parte hearing, check box and insert date and time for
adversary hearing.

5. Check box and provide basis upon which order is entered when entered pursuant to an ex
parte proceeding and no affidavit is provided.

6. Insert facts justifying the issuance of the preliminary protective order (required for using
order as part of notice for the adversary hearing).

7. Check box, if applicable, and check appropriate box for the court findings.

8. Check box, if applicable, and insert name of person objecting.

9. If applicable, insert date and time of adjudicatory hearing.

10. Insert date and time of dispositional hearing.

11. If applicable, check box and insert date and time for review hearing.

12. Insert date of entry of order.

13. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
RETURNS: Each person was served according to law, as indicated 1
Case No. ......................................................................................
below, unless not found.
2
In re: .............................................................................................
PERSON (NO. 1) SUBJECT TO THIS ORDER: PERSON (NO. 2) SUBJECT TO THIS ORDER:
3
NAME ................................................................................................................. 3
NAME .................................................................................................................

[ ] PERSONAL SERVICE 4 [ ] PERSONAL SERVICE 4

5 TELEPHONE NO. .........................................
5
TELEPHONE NO. ..........................................

6 [ ] NOT FOUND
6[ ] NOT FOUND

7
______________________________________________________________ 7
______________________________________________________________
SERVING OFFICER SERVING OFFICER

8
for ___________________________________________________________ 8
for ___________________________________________________________

9
............................................................................................................................. 9
..............................................................................................................................
DATE AND TIME DATE AND TIME

Respondent’s Description (for VCIN) Respondent’s Description (for VCIN)

RACE ......................................... 10 SEX ................................................ RACE ........................................ 10 SEX ................................................
DOB ...................................................................................................................... DOB ......................................................................................................................
HGT ........................................... WGT ............................................... HGT ........................................... WGT ..............................................
EYES ......................................... HAIR .............................................. EYES ......................................... HAIR ..............................................
SSN ....................................................................................................................... SSN .......................................................................................................................
Telephone No. ....................................................................................................... Telephone No. .......................................................................................................
Relationship to Petitioner/Plaintiff ........................................................................ Relationship to Petitioner/Plaintiff ........................................................................
Distinguishing features .......................................................................................... q Distinguishing features .........................................................................................

PERSON AGE 12 OR OLDER PROTECTED BY ORDER: FAMILY MEMBER OF PROTECTED PERSON:

(See form DC-621, NON-DISCLOSURE ADDENDUM.) (See form DC-621, NON-DISCLOSURE ADDENDUM.)

11
NAME ................................................................................................................. 12
NAME .................................................................................................................

5 [ ] PERSONAL SERVICE 5[ ] PERSONAL SERVICE

6 [ ] NOT FOUND 6[ ] NOT FOUND

7
______________________________________________________________ 7
______________________________________________________________
SERVING OFFICER SERVING OFFICER

8
for ___________________________________________________________ 8
for ___________________________________________________________

PETITIONER: 14
_______________________________________________________________
[ ] See form DC-621, NON-DISCLOSURE ADDENDUM. RELATIONSHIP TO PERSON PROTECTED BY ORDER

13
NAME .................................................................................................................
[ ] See form DC-621, NON-DISCLOSURE ADDENDUM.

.............................................................................................................................
15
NAME .................................................................................................................

..............................................................................................................................
5 [ ] PERSONAL SERVICE
5[ ] PERSONAL SERVICE
6 [ ] NOT FOUND
6[ ] NOT FOUND
7
______________________________________________________________
SERVING OFFICER
7
______________________________________________________________
SERVING OFFICER
8
for ___________________________________________________________ 8
for ___________________________________________________________
9
............................................................................................................................. 9
..............................................................................................................................
DATE AND TIME DATE AND TIME

FORM DC-527 (MASTER, PAGE THREE OF _____) 04/13

Form DC-527 PRELIMINARY CHILD PROTECTIVE ORDER – Form DC-527
ABUSE AND NEGLECT

Data Elements, page three

1. Insert court case number.

2. Insert case name.

3. Insert name of person who is the subject to the order.

4. Insert address and telephone number of person who is subject to the order.

5. Serving officer to check this box if personal service obtained.

6. Serving officer to check this box if person to be served is not found.

7. Signature of serving officer.

8. Insert name of jurisdiction/agency. Insert name of sheriff if served by deputy sheriff.

9. Insert date and time of service.

10. Enter identifying information for respondent(s), if known.

11. Insert name of the person age 12 or older who is protected by the order. (See Using This
Form, 4.d.)

12. Insert name of the family member of the person who is protected by the order. (This may
be the person with whom the protected child lives or another family member whose
address information should not be disclosed.) (See Using This Form, 4.d.)

13. Insert the petitioner’s name. Do not provide petitioner’s address and telephone number.
(See Using This Form, 4.d.)

14. Insert relationship to the protected person of the person to be served.

15. Insert name of the person to be served. Do not provide person’s address and telephone
number. (See Using This Form, 4.d.)

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
Form DC-528 PRELIMINARY REMOVAL ORDER Form DC-528

Using This Form

1. Copies

a. Original--to the court.

b. First copy--to parents or persons having custody of the child prior to removal.

c. Second copy--to person or agency to whom custody has been temporarily granted by this
order.

d. Other copies as determined by local practice.

2. Prepared by clerk, signed by judge.

3. Attachments

a. Copy of DC-526, EMERGENCY REMOVAL ORDER, if one was previously issued.

b. DC-510, SUMMONS, and DC-511, JUVENILE PETITION, with affidavit (if used).

c. DC-508, ACKNOWLEDGMENT OF NOTICE OF NEXT HEARING DATE.

4. Preparation details

a. It has been suggested that the street address of the person or agency to whom custody was
granted should not be included to prevent unauthorized visitation or the commission of
violent acts against the child by the person from whose custody the child was removed.
Alternatively, the same information may be placed on a separate sheet in the case file.

b. All executions must be fully completed even if the same officer serves the papers and
removes the juvenile to the place described in the ORDER. If more than one officer will
be performing these services, an extra copy for return of service of process should be
completed.

DISTRICT COURT MANUAL FORMS VOLUME

MAY 2003
Form DC-528 PRELIMINARY REMOVAL ORDER Form DC-528

Data elements, front

1. Insert court case number.

2. Insert date of hearing at which this order is entered.

3. Insert court name.

4. Insert case name (name of child who is the subject of this action).

5. Check the applicable boxes for those present at the hearing and insert their names on the
dotted lines provided.

6. Check the box if removal of the child is being ordered or continued.

7. Check the box, if applicable.

8. Check the box, if applicable, and specify facts that substantiate imminent threat to the child.

9. Check the appropriate box.

10. Check the box, if applicable.

11. Check the box, if applicable, and specify facts that substantiate efforts made by the agency to
prevent removal of the child from his or her home.

12. Check the box if applicable, and insert date child was removed.

13. Insert name, and (if appropriate) street address, of person or agency having temporary
legal custody of the child pursuant to this order.

14. Check box, if applicable, and insert name of agency or person directed by the court to
conduct an investigation of the temporary custodian.

DISTRICT COURT MANUAL FORMS VOLUME

MAY 2003
Case No. 1
..............................................

2
C. [ ] That reasonable visitation be allowed between the child and his or her parents, guardian, legal custodian or other person
standing in loco parentis, namely: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
........................................................................................................................................................................

3[ ] That no visitation be allowed between the child and his or her parents, guardian, legal custodian or other person standing in
loco parentis, as such visitation would endanger the child’s life or health.
D. 4[ ] That 4
.......................................................................................................................... shall provide the following
AGENCY
social services to the child and the temporary custodian: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
................................................
E. That, if the Court orders the child to be placed in foster care, the local department of social service shall pursue child support
in accordance with Virginia Code § 16.1-290.
F. 6[ ] Other: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
.....................................................................................................

ADJUDICATION OF PETITION ALLEGING ABUSE OR NEGLECT:

7 [ ] The Court finds, by a preponderance of the evidence, that the child is abused or neglected.
8 [ ] An objection having been made by 8
............................................................................................................................
pursuant to Virginia Code § 16.1-252 G to the Court’s entering a finding with respect to the allegation of abuse or neglect, an
adjudicatory hearing is set for . . . . . . . . . . . . . . . . . . . . . . . .9
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at 9
.............................. m. This ORDER shall
remain in full force and effect pending the adjudicatory hearing.

A dispositional hearing shall be held pursuant to Virginia Code § 16.1-278.2 on . . . . . . . . . . . . . . . .10

. . . . . . . . . . . . . . . . . . . . . at .................. m.
[ ] The local department of social services shall file a foster care plan pursuant to Virginia Code § 16.1-281 by . . . . . . . . . . . . . .11
..............
DATE

12
...................................................... 13
_________________________________________________________
DATE JUDGE

EXECUTED by taking the child into custody on 14

..................................... at 14
............................ m. and placing the child with
15
................................................................................................ . . . . . . . . . . . . . . . . . . . . at . . . . . . .16
on . . . . . . . . . . . . . . . . . .16 . . . . . . . . . . . m.
PERSON OR AGENCY GRANTED CUSTODY

17
...................................................... 18
................................................................................................
DATE SERVING OFFICER
19
_________________________________________________
BADGE NO., AGENCY AND JURISDICTION
for 20
_________________________________________________
SHERIFF

RETURNS: Each person was served according to law, as indicated below, unless not found.

NAME 21
.................................................. NAME ................................................... NAME ................................................

.................................................................. ......................................................... ......................................................

ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

........................................................ ......................................................... ......................................................

[ ] PERSONAL SERVICE
22 Tel.
No. . . . . . . . . . . . . . . . . . . . .
[ ] PERSONAL SERVICE Tel.
No. . . . . . . . . . . . . . . . . . . . . .
[ ] PERSONAL SERVICE Tel.
No. . . . . . . . . . . . . . . . . . .

23 [ ] NOT FOUND [ ] NOT FOUND [ ] NOT FOUND

24
__________________________________ __________________________________ ________________________________
SERVING OFFICER
SERVING OFFICER SERVING OFFICER
25
for _______________________________ for _______________________________ for _____________________________

FORM DC-528 (REVERSE) REVISED 5/03

Form DC-528 PRELIMINARY REMOVAL ORDER Form DC-528

Data Elements, reverse

1. Insert case number. 17. Insert date of signature of serving

officer.
2. If visitation rights are to be given,
check this box and insert the terms and 18. Signature of serving officer.
conditions of the visitation rights.
19. Insert badge number, agency, and
2. Check this box if no visitation rights name of jurisdiction employing
are allowed. serving officer.
3. Check this box if the court has ordered 20. If served by deputy sheriff, print or
social services to be provided to the type name of sheriff.
child and temporary custodian.
21. Name and address (and telephone
4. Insert name of agency to provide number if known) of party to be served
social services. (to be inserted by clerk or judge).
5. Insert social services to be provided. 22. Serving officer to check this box if
personal service obtained.
6. Check the box, if applicable, and insert
other orders of the Court. 23. Serving officer to check this box if
unable to serve process.
7. Check this box, if applicable.
24. Signature of serving officer.
8. Check box, if applicable, and insert
name of person objecting. 25. Insert name of sheriff if served by
deputy.
9. If applicable, insert date and time of
adjudicatory hearing.
10. Insert date and time of dispositional
hearing.
11. If the child is placed in foster care
check the box and insert the date by
which the foster care plan must be
filed.
12. Insert date of entry of order.
13. Signature of judge issuing this order.
14. Insert date and time that the child was
taken into custody.
15. Insert name of person or agency to
whom child was delivered.
16. Insert date and time that the child was
delivered into custody of person or
agency.
DISTRICT COURT MANUAL FORMS VOLUME
MAY 2003
Form DC-529 DETENTION ORDER Form DC-529

Using This Form

1. Copies

a. Original – to court.

b. First copy – to detention facility.

c. Additional copies as determined by local practice.

2. Prepared by clerk, judge or intake officer.

3. Attachments

a. Forms DC-510, SUMMONS, and DC-511, JUVENILE PETITION – if both are

prepared and issued at the same time as the DETENTION ORDER.

4. Preparation details

a. Information in Data Element No. 4 is used to provide identification information

for law enforcement personnel. Complete Data Element No. 4 only if forms
DC-510, SUMMONS and DC-511, JUVENILE PETITION are not attached and
complete only those items in Data Element No. 4 for which you have accurate
information.

b. This form should not be used in place of form DC-523, EMERGENCY REMOVAL
ORDER, which is used when the child is the victim of someone else’s actions and
needs to be removed from the custody of the person having custody over the
child.

c. This form should not be used to place a juvenile in shelter care. Use form
DC-530, SHELTER CARE ORDER, to place a juvenile in a shelter care facility.

d. Remember to complete the custody and placement provisions on the court copy of
form DC-511, JUVENILE PETITION, when the child is taken into custody.

e. If known, pending and previous charges against this juvenile are to be listed.

DISTRICT COURT MANUAL FORMS VOLUME

JANUARY 2013
DETENTION ORDER Case No. . . . . . . . . . . . . . . . . . . . .1
.................................................
Commonwealth of Virginia Va. Code §§ 16.1-247(A & D), 16.1-248.1, 16.1-250 F, 16.1-256

2
...................................................................................................... Juvenile and Domestic Relations District Court
In re: 3
.........................................................................................................................................................................
JUVENILE SOCIAL SECURITY NUMBER

Other Pending and Previous Charges: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

....................................................................................................................................................................................

6 To be completed ONLY if petition is not attached to this order. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DATE OF BIRTH

It appears from the petition or warrant filed concerning the juvenile that the juvenile may come within the purview of the Juvenile and
Domestic Relations District Court Law, and it further appears that the welfare of the juvenile requires that his or her custody be
immediately assumed by the Court, in that there is probable cause to believe that the juvenile committed the act alleged in the petition
or warrant and:

[ ] The juvenile is alleged to have

[ ] committed an act that would be a felony or Class 1 misdemeanor if committed by an adult,
[ ] violated the terms of probation or parole when the charge for which he/she was placed on probation or parole would have
been a felony or Class 1 misdemeanor if committed by an adult
AND there is clear and convincing evidence that:
[ ] the release of the juvenile constitutes a clear and substantial threat to the person or property of others; or
[ ] the release of the juvenile would present a clear and substantial threat of serious harm to such juvenile’s life
or health; or
7 [ ] the juvenile has threatened to abscond from the court’s jurisdiction during the pendency of the instant proceedings
or has a record of willful failure to appear at a court hearing within the immediately preceding twelve months.
[ ] The juvenile absconded from a detention home or facility where he has been directed to remain by the lawful order of a
judge or intake officer.
[ ] The juvenile is a fugitive from a jurisdiction outside Virginia and subject to verified petition or warrant.
[ ] The juvenile has failed to appear in court after having been duly served with a summons in any case in which it is alleged
that the juvenile has committed a delinquent act or that the juvenile is in need of services or the juvenile is in need of
supervision.
[ ] The juvenile failed to adhere to the previously imposed conditions following his release upon a Class 1 misdemeanor charge or a
felony charge.
It is hereby ORDERED that the juvenile be taken into immediate custody and be brought before a judge or intake officer. If court is
NOT open, the juvenile shall be placed in the custody of:
8
..............................................................................................................., a secure facility, until brought before the Court
NAME OF AGENCY OR FACILITY
on the next day on which the court sits, not to exceed 72 hours. However, if the 72 hours expires on a Saturday, Sunday, legal holiday,
or day on which the court is lawfully closed, the juvenile shall be brought before the court on the next day that is not a Saturday,
Sunday, legal holiday or day on which the court is lawfully closed.

9 [ ] SPECIAL INSTRUCTIONS: (See reverse if checked)

. . . . . . . . . . . . . . . .10
.................... 11
________________________________________________________________
DATE [ ] CLERK [ ] JUDGE [ ] INTAKE OFFICER [ ] MAGISTRATE

FORM DC-529 (MASTER, PAGE ONE OF TWO) 10/12

Form DC-529 DETENTION ORDER Form DC-529

Data Elements, page one

1. Insert court case number.

2. Insert court name.

3. Insert case name (name of juvenile) and social security number.

4. Insert charges on which child is to be detained.

5. List other pending and previous charges against the juvenile, if known.

6. If forms DC-510, SUMMONS, and DC-511, JUVENILE PETITION, are not attached, insert
appropriate information concerning juvenile to be detained.

7. Check the box(es) for the appropriate reason for taking the child into immediate custody.
If the first box is checked, also check one of the two boxes indented under the first box.

8. Insert the name of the detention facility in which child is to be placed if court is not open.

9. If any special instructions, check the box and insert instructions on page 2.

10. Insert date of entry of order.

11. Signature of judge, clerk, magistrate or intake officer. Check the appropriate title box
below the signature line.

DISTRICT COURT MANUAL FORMS VOLUME

JANUARY 2013
SPECIAL INSTRUCTIONS

Parents notified on 11
....................................................................................
EXECUTED by taking the juvenile into custody DATE
a.m.
2
on ........................................................................ at 3
.............................. p.m. at 12
........................................................................... of detention hearing
TIME

INTAKE
and placing the juvenile with 13
_______________________________________________________________________________ OFFICER

4
.................................................................................................................................
PERSON OR AGENCY GRANTED CUSTODY

a.m.
5
on ........................................................................ at 6
.............................. p.m.
7
.................................................................................................................................
DATE

8
SERVING
_______________________________________________________________________________ OFFICER

9
.................................................................................................................................
BADGE NO., AGENCY AND JURISDICTION

10
for .........................................................................................................................
SHERIFF

RETURNS: Each person was served according to law, as indicated below, unless not found.

NAME: ......................................................................... NAME: .........................................................................

14 NAME: ........................................................................
...................................................................................... ..................................................................................... .....................................................................................
ADDRESS: .................................................................... ADDRESS: .................................................................... ADDRESS: ....................................................................

...................................................................................... ..................................................................................... .....................................................................................

15 [ ] PERSONAL SERVICE
Tel.
No. .................................... [ ] PERSONAL SERVICE
Tel.
No. ....................................
[ ] PERSONAL SERVICE
Tel.
No. ....................................

[ ] Being unable to make personal service, a copy was [ ] Being unable to make personal service, a copy was [ ] Being unable to make personal service, a copy was
delivered in the following manner: delivered in the following manner: delivered in the following manner:

[ ] Delivered to family member (not temporary sojourner [ ] Delivered to family member (not temporary sojourner [ ] Delivered to family member (not temporary sojourner
or guest) age 16 or older at usual place of abode of or guest) age 16 or older at usual place of abode of or guest) age 16 or older at usual place of abode of
16 party named above after giving information of its
purport. List name, age of recipient, and relation of
party named above after giving information of its
purport. List name, age of recipient, and relation of
party named above after giving information of its
purport. List name, age of recipient, and relation of
recipient to party named above. recipient to party named above. recipient to party named above.

17
............................................................................ ............................................................................. ............................................................................
............................................................................ ............................................................................. ............................................................................
[ ] Posted on front door or such other door as appears [ ] Posted on front door or such other door as appears [ ] Posted on front door or such other door as appears
to be the main entrance of usual place of abode, to be the main entrance of usual place of abode, to be the main entrance of usual place of abode,
address listed above. (Other authorized recipient not address listed above. (Other authorized recipient not address listed above. (Other authorized recipient not
found.) found.) found.)

18  Not found 19  Not found  Not found

SERVING OFFICER SERVING OFFICER
20
.......................... 21
for__________________________ .........................
SERVING OFFICER
for__________________________ ......................... for__________________________
DATE DATE DATE

FORM DC-529 (MASTER, PAGE TWO OF TWO) 05/09

Form DC-529 DETENTION ORDER Form DC-529

Data Elements, page two

1. If Data Element No. 7 (on page 1) is checked, insert special instructions here.

2. Date on which juvenile was taken into custody by serving officer.

3. Time at which juvenile was taken into custody.

4. Person or agency to whom juvenile was delivered.

5. Date on which juvenile was delivered into custody o person or agency.

6. Time at which juvenile was delivered into custody.

7. Date of signature of serving officer.

8. Signature of serving officer.

9. Badge number, agency, and name of jurisdiction employing serving officer.

10. If served by deputy sheriff, print or type name of sheriff.

11. Date on which parents were notified of detention hearing.

12. Time at which parents were notified of detention hearing.

13. Signature of intake officer who notified parents.

14. Name and address (and telephone number if known) of party to be served (to be inserted
by clerk or judge).

15. Serving officer to check this box if personal service obtained.

16. Serving officer to check the appropriate box to designate type of substitute service.

17. If served by leaving a copy with a family member age 16 or older, check appropriate box
and insert required information.

18. Serving officer to check this box if unable to serve process.

19. Signature of serving officer.

20. Date of signature.

21. Name of sheriff if served by deputy sheriff.

DISTRICT COURT MANUAL FORMS VOLUME

JANUARY 2013
Form DC-530 SHELTER CARE ORDER Form DC-530

Using This Form

1. Copies
a. Original – to court.

b. First copy – to shelter care facility.

c. Additional copies as determined by local practice.

2. Prepared by clerk, judge or intake officer.

3. Attachments – Form DC-510, SUMMONS, and form DC-511, JUVENILE PETITION, if both
are issued at the same time as the SHELTER CARE ORDER.

4. Preparation details

a. Information in Data Element No. 4 is used to provide information for law

enforcement personnel. Complete Data Element No. 4 only if form DC-510,
SUMMONS, and form DC-511, JUVENILE PETITION, are not attached, and complete
only those elements for which you have accurate information.

b. This form should not be used in place of form DC-526, EMERGENCY REMOVAL
ORDER, which is used when the child is the victim of someone else’s actions and
needs to be removed from the custody of the person having custody over him.

NOTE: A separate form DC-610, PETITION FOR SUPPORT (CIVIL), and form DC-628,
ORDER OF SUPPORT (CIVIL), should be used to determine and fix the amount of support.

DISTRICT COURT MANUAL FORMS VOLUME

REVISED JULY 1997
SHELTER CARE ORDER 1
CASE NO. ....................................................................................
VA. CODE ANN. §§ 16.1-274(D), 16.1-248.1, 16.1-249, 16.1-252, 16.1-256, 16.1-290

To be completed ONLY if petition or warrant is not attached to this order.

4 ................................... ............................................. ................................... ...................................................... ............................................

AGE RACE SEX WEIGHT HEIGHT

It appears from the petition or warrant filed concerning the juvenile that the juvenile may come within the purview of the
Juvenile and Domestic Relations District Court Law, and it further appears that the welfare of the juvenile requires that his custody be
immediately assumed by the Court, in that

[ ] 1. The child is eligible for placement in a secure facility; or

[ ] 2. The child has failed to adhere to the directions of the court, intake officer or magistrate while on conditional release; or

[ ] 3. The child’s parent, guardian or other person able to provide supervision cannot be reached within a reasonable time; or

5 [ ] 4. The child does not consent to return home; or

[ ] 5. Neither the child’s parent or guardian nor any other person able to provide proper supervision can arrive to assume custody
within a reasonable time; or

[ ] 6. The child’s parent or guardian refuses to permit the child to return home and no relative or other person willing and able to
provide proper supervision and care can be located within a reasonable time.

It is hereby ORDERED that the juvenile be taken into immediate custody and be brought before a judge or intake officer or magistrate
if neither the judge nor the intake officer is reasonably available. If court is NOT open, the juvenile shall be placed in the custody of:
6
.................................................................................................................................................................. , a shelter care facility, there to remain until brought
NAME OF AGENCY OR FACILITY
before the Court on the next day on which the court sits as provided by law.

7[ ] and that pursuant to a hearing before the court, ............................................................................................... is ordered to pay child support in

the amount of .................................................... per ............................................ to ...................................................................................................................

for the duration of the placement.

SPECIAL INSTRUCTIONS:
8

9
................................................................................. ______________________________________________________________________ 10
DATE [ ] JUDGE [ ] INTAKE OFFICER [ ] MAGISTRATE

CASE NO. 1
..........................................................................................

FORM DC-530 (MASTER, PAGE ONE OF TWO) 7/96 PDF

Form DC-530 SHELTER CARE ORDER Form DC-530

Data Elements, front

1. Court case number.

2. Court name.

3. Name of juvenile.

4. If form DC-510, SUMMONS, and form DC-511, JUVENILE PETITION, are not attached,
insert appropriate information concerning juvenile.

5. Check the box stating the reason for placing child in shelter care.

6. Insert the name of the shelter care facility in which the child is to be placed if court is not
open.

7. Check box and indicate amount due and to whom payable.

8. Insert special instructions, if any.

9. Date of entry of order.

10. Signature of judge, magistrate or intake officer. Check the appropriate title box below
the signature line.

DISTRICT COURT MANUAL FORMS VOLUME

REVISED JULY 1997
RETURNS: Each person was served according to law, as indicated below, unless not found.

1
NAME ............................................................................ NAME .............................................................................. NAME ............................................................................
......................................................................................... ............................................................................................ ..........................................................................................
ADDRESS ..................................................................... ADDRESS ........................................................................ ADDRESS ......................................................................

......................................................................................... ............................................................................................ ..........................................................................................

Tel. Tel. Tel.

2 [ ] PERSONAL SERVICE
No. ...............................
[ ] PERSONAL SERVICE
No. ...............................
[ ] PERSONAL SERVICE
No. ...............................
Being unable to make personal service, a copy was
delivered in the following manner: Being unable to make personal service, a copy was delivered Being unable to make personal service, a copy was
in the following manner: delivered in the following manner:
3 [ ] Delivered to family member (not temporary sojourner or
guest) age 16 or older at usual place of abode of party [ ] Delivered to family member (not temporary sojourner or [ ] Delivered to family member (not temporary sojourner or
named above after giving information of its purport. List guest) age 16 or older at usual place of abode of party guest) age 16 or older at usual place of abode of party
name, age of recipient, and relation of recipient to party named above after giving information of its purport. List named above after giving information of its purport. List
named above. name, age of recipient, and relation of recipient to party name, age of recipient, and relation of recipient to party
4
............................................................................................
named above. named above.
............................................................................................ .......................................................................................
............................................................................................
............................................................................................ .......................................................................................
[ ] Posted on front door or such other door as appears to be
the main entrance of usual place of abode, address listed [ ] Posted on front door or such other door as appears to be [ ] Posted on front door or such other door as appears to be
above. (Other authorized recipient not found.) the main entrance of usual place of abode, address listed the main entrance of usual place of abode, address listed
above. (Other authorized recipient not found.) above. (Other authorized recipient not found.)

5[ ] Not found 6
_____________________ [ ] Not found
_____________________ [ ] Not found
____________________
SERVING OFFICER SERVING OFFICER SERVING OFFICER

7
.............................. for _________________________ 8 .............................. for _________________________ ............................... for __________________________
DATE DATE DATE

FORM DC-530 (MASTER, PAGE TWO OF TWO) 7/91 PDF

Form DC-530 SHELTER CARE ORDER Form DC-530

Data Elements, reverse

1. Name and address (and telephone number, if known) of party to be served (to be inserted
by clerk or judge).

2. Serving officer to check this box if personal service obtained.

3. Serving officer to check the appropriate box to designate type of substitute service.

4. If served by leaving a copy with a family member age 16 or older, check appropriate box
and insert required information.

5. Serving officer to check this box if unable to serve process.

6. Signature of serving officer.

7. Date of signature.

8. Name of sheriff if served by deputy sheriff.

DISTRICT COURT MANUAL FORMS VOLUME

REVISED JULY 1997
Form DC-531 ORDER FOR TERMINATION OF Form DC-531
RESIDUAL PARENTAL RIGHTS

Using This Form

1. Copies

a. Original – to court.

b. First copy – to parent.

c. Second copy – to person or entity granted custody.

d. Additional copies as dictated by local practice.

2. Prepared by clerk, signed by judge.

3. Attachments

a. Form DC-535, NOTICE OF TERMINATION OF RESIDUAL PARENTAL RIGHTS

b. Form DC-559, SUPPLEMENT TO ORDER TRANSFERRING CUSTODY, if used.

4. Preparation details

a. This form is used only when residual parental rights are terminated involuntarily.
Please note that in cases which involve an entrustment agreement or where the
parents have sought to be relieved of custody and authorize adoption, district
court form DC-534, ORDER FOR VOLUNTARY TERMINATION OF RESIDUAL
PARENTAL RIGHTS, should be used.

b. This form should not be used if the court does not terminate parental rights.

c. Only one parent should be included on each form.

d. More than one box corresponding to the different sections of Va. Code § 16.1-283
under 1a., Data Element Nos. 11, 12, 14-18 and 2 or 3 on reverse, may be checked
based on the circumstances of the case.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2004
ORDER FOR INVOLUNTARY TERMINATION OF Case No. . . . . . . . . . . . . . . . . . .1
.....................................................
RESIDUAL PARENTAL RIGHTS
Commonwealth of Virginia Va. Code § 16.1-283 2
...................................................................................
DATE OF HEARING
[ ] Circuit Court
3
............................................................................................... [ ] Juvenile and Domestic Relations District Court

In re: 4
........................................................................... 5
...................................................................................
NAME OF CHILD DATE OF BIRTH

6
................................................................................... 7
...................................................................................
NAME OF PARENT ([ ] FATHER [ ] MOTHER) PARENT’S ATTORNEY
9
8
................................................................................... ,
Petitioner, alleges that the above-named child comes within the jurisdiction
of the Juvenile and Domestic Relations District Court law. The parties have been informed of their right to representation by a lawyer. Due
notice of the proceedings has been given to the parties by the court. If no summons or notification is required pursuant to Virginia Code
§ 16.1-263, I, the undersigned judge, certify that the identity of the [ ] father [ ] mother [ ] guardian is not reasonably ascertainable.

10
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . was appointed by the Court as guardian ad litem for the child.
NAME OF ATTORNEY

A foster care plan, which documents termination of parental rights as being in the best interests of the child, has been filed pursuant to
Virginia Code § 16.1-281 and has been approved by the Court.

1. Having heard the evidence and determined that the child comes within the jurisdiction of this court, the Court finds, based upon clear and
convincing evidence, that:
11 a. [ ] Va. Code § 16.1-283 B
The neglect or abuse suffered by such child presents a serious and substantial threat to his or her life, health or
development; and
It is not reasonably likely that the conditions which resulted in such neglect or abuse can be substantially corrected or
eliminated so as to allow the child’s safe return to his or her parent within a reasonable period of time.

12 [ ] Va. Code § 16.1-283 C

[ ] The above-named parent, without good cause, has failed to maintain continuing contact with and to provide or
substantially plan for the future of the child for a period of six months after the child’s placement in foster care
13 notwithstanding the reasonable and appropriate efforts of social, medical, mental health or other rehabilitative
agencies to communicate with the parent and to strengthen the parent-child relationship; or

[ ] The above-named parent, without good cause, has been unwilling or unable within a reasonable period of time not to
exceed twelve months from the date the child was placed in foster care to remedy substantially the conditions which
led to or required continuation of the child’s foster care placement, notwithstanding the reasonable and appropriate
efforts of social, medical, mental health or rehabilitative agencies to such end.

14 [ ] Va. Code § 16.1-283 D

The child was abandoned under such circumstances that either the identity or the whereabouts of the above-named parent
cannot be determined; and
The child’s parent or parents, guardian or relatives have not come forward to identify such child and claim a relationship to
the child within three months following the issuance of an order by the court placing the child in foster care; and
Diligent efforts have been made to locate the child’s parent without avail.

15 [ ] Va. Code § 16.1-283 E (i)

The residual parental rights of the above-named parent to a sibling have previously been involuntarily terminated.

16 [ ] Va. Code § 16.1-283 E (ii)

The above-named parent of the child has been convicted of an offense under the laws of this Commonwealth or a
substantially similar law of any other state, the United States or any foreign jurisdiction that constitutes murder or voluntary
manslaughter, or a felony attempt, conspiracy or solicitation to commit any such offense and the victim of the offense was a
child of the parent, a child with whom the parent resided at the time such offense occurred or the other parent of the child.

FORM DC-531 (MASTER, PAGE ONE OF TWO) 7/02

Form DC-531 ORDER FOR TERMINATION OF Form DC-531
RESIDUAL PARENTAL RIGHTS

Data Elements, page one

1. Insert court case number.

2. Insert date of hearing.

3. Insert court name. Check box for appropriate court.

4. Insert name of child who is the subject of the proceeding.

5. Insert date of birth of child.

6. Insert name of parent and check box to indicate whether father or mother.

7. Insert name of parent’s attorney.

8. Insert name of petitioner.

9. Check one box, if applicable.

10. Insert name of attorney appointed as guardian ad litem.

11. Check if parental rights are being terminated pursuant to Virginia Code § 16.1-283B to
document the court’s findings and conclusions.

12. Check the first check box if parental rights of the parent are being terminated pursuant to
Virginia Code § 16.1-283C.

13. Check the box(es) to document the court’s findings and conclusions.

14. Check if parental rights are being terminated pursuant to Virginia Code § 16.1-283D to
document the court’s findings and conclusions.

15. Check if parental rights are being terminated pursuant to Virginia Code § 16.1-283E(i) to
document the court’s findings and conclusions.

16. Check if parental rights are being terminated pursuant to Virginia Code § 16.1-283E(ii) to
document the court’s findings and conclusions.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2004
Case No. 1
......................................................................

2 [ ] Va. Code § 16.1-283 E (iii).

The above-named parent of the child has been convicted of an offense under the laws of this Commonwealth or a
substantially similar law of any other state, the United States or any foreign jurisdiction that constitutes felony assault
resulting in serious bodily injury or felony bodily wounding resulting in serious bodily injury or felony sexual assault and
the victim of the offense was a child of the parent or a child with whom the parent resided at the time of such offense.

3 [ ] Va. Code § 16.1-283 E (iv).

The above-named parent of the child has subjected the child to aggravated circumstances.

AND, in accordance with Virginia Code § 16.1-283 G,

b. [ ] The child is not 14 years old or older nor is otherwise of an age of discretion.
[ ] The child is 14 years old or older, has a disability that reduces his or her developmental age, and is not otherwise of an age
4 of discretion.
[ ] The child does not object to the termination of residual parental rights of the above-named parent and is:
[ ] age 14 years old or older, or [ ] not age 14 years old but is otherwise of an age of discretion.
c. It is in the child’s best interests that the residual parental rights of the above-named parent be terminated.

d. The Court further finds that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

.....................................................................................................

................................................................................................................................................................................

2. The Court ORDERS that the residual parental rights of 6

.........................................................................................................
NAME OF PARENT
which include, but are not limited to, the right of visitation, consent to adoption and right to determine religious affiliation be terminated.

3. The Court ORDERS that the child is committed to the care and custody of 7
...............................................................................
PUBLIC OR PRIVATE CHILD-PLACING AGENCY OR INDIVIDUAL / ADDRESS

8[ ] If legal custody of the child is transferred to a relative or other interested individual, district court form DC-559, SUPPLEMENT TO
ORDER TRANSFERRING CUSTODY, is attached and incorporated in this order.

4. 9 [ ] The Court ORDERS that the department or agency shall have the authority to place the child for adoption and consent thereto, shall
make permanent plans for the placement of the child, and shall file an Adoption Progress Report pursuant to Virginia Code
§ 16.1-283 F on 10
................................................. .
DATE
5.11[ ] Other: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.............................................................................................................................................................................

6.12[ ] This order having been entered in the. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Circuit Court,
CITY OR COUNTY

the matter is referred pursuant to Virginia Code § 16.1-297 to the 12

................................................................... Juvenile and
CITY OR COUNTY
Domestic Relations District Court for future proceedings.

This ORDER is final.

13
........................................................... 14
_____________________________________________________
DATE JUDGE

FORM DC-531 (MASTER, PAGE TWO OF TWO) 5/04

Form DC-531 ORDER FOR TERMINATION OF Form DC-531
RESIDUAL PARENTAL RIGHTS

Data Elements, page two

1. Insert case number.

2. Check if parental rights are being terminated pursuant to Virginia Code § 16.1-283E(iii)
to document the court’s findings and conclusions.

3. Check if parental rights are being terminated pursuant to Virginia Code § 16.1-283E(iv)
to document the court’s findings and conclusions.

4. Check applicable box(es) that corresponds to the court’s findings and conclusions.

5. Insert statement of specific facts supporting conclusion checked on front of form or

above.

6. Insert name of parent whose rights are being terminated.

7. Insert name of person or entity to whom the court granted custody, with address.

8. Check the applicable box if custody is transferred to relative or other interested

individual. If so, complete and attach form DC-559, SUPPLEMENT TO ORDER
TRANSFERRING CUSTODY.

9. Check this box if the agency is given permission by the court to place the child for
adoption after a final order has been entered.

10. Insert date on which the adoption progress report is due.

11. Check the box and complete if there are additional provisions.

12. If order is being entered by the Circuit Court and the case is being remanded to the
juvenile and domestic relations district court, check box and insert the name of the
locality(ies) of the involved courts.

13. Insert date of entry of order.

14. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2004
Form DC-532 CHILD PROTECTIVE ORDER – Form DC-532
ABUSE AND NEGLECT

Using This Form

1. Copies

a. Original – to court.

b. Copy – to parent or other person named in Data Element No. 9.

c. Copy – to parent if different from individual referred to in 1.b., above.

d. Copy – to investigatory entity named in paragraph 3 on page one of form.

e. Copy – to local law enforcement agency for service.

2. Prepared by clerk, signed by judge.

3. Attachments

Form DC-621, NON-DISCLOSURE ADDENDUM, for person age 12 or older who is

protected by the order, a family member of the protected person and others as
appropriate.

4. Preparation details

a. This form can accommodate two respondents where the conditions are the same
and the same child is being protected.

b. If statement of conditions on page one (Data Element No. 11, paragraph 8) exceed
the space allotted, use form DC-547, SUPPLEMENTAL SHEET TO CHILD
PROTECTIVE ORDER.

c. With page two, complete form DC-621, NON-DISCLOSURE ADDENDUM, for the
person age 12 or older who is protected by the order, family member of the
protected person, and, as appropriate, for the petitioner and other person whose
address information should not be disclosed.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
CHILD PROTECTIVE ORDER – ABUSE AND NEGLECT 1
Juvenile Case No. ....................................................................
Commonwealth of Virginia Va. Code §§ 16.1-253, 16.1-278.2
2
.........................................................................................................
DATE OF HEARING
3
.......................................................................................................................................................................... Juvenile and Domestic Relations District Court
4
In re: ................................................................................................................................................. ................................................................................................
NAME OF CHILD DATE OF BIRTH
Present:
[ ] Mother ......................................................................................... [ ] Mother’s attorney ......................................................................................
[ ] Father ........................................................................................... [ ] Father’s attorney ........................................................................................
5 [] Child .......................................................................................... [ ] Guardian ad litem ......................................................................................
[ ] Agency representative ........................................................... [ ] Agency attorney ........................................................................................
[ ] Other .......................................................................................... [ ] CASA ............................................................................................................
COMPLETE DATA BELOW IF KNOWN COMPLETE DATA BELOW IF KNOWN
DESCRIPTION OF PERSON (No. 1) SUBJECT TO THIS ORDER DESCRIPTION OF PERSON (No. 2) SUBJECT TO THIS ORDER

NAME: 6 NAME: 6
RACE SEX BORN HT. WGT. EYES HAIR RACE SEX BORN HT. WGT. EYES HAIR
MO. DAY YR. FT. IN. MO. DAY YR. FT. IN.

SSN SSN

Check if applicable:
7 [[ ]] Relationship
Relationship of person No. 1 to child’s parent: [ ] child’s other parent [ ] spouse/former spouse [ ] cohabit in present or past.
of person No. 2 to child’s parent: [ ] child’s other parent [ ] spouse/former spouse [ ] cohabit in present or past.
8 It appearing that the above-named child is within the purview of the Juvenile and Domestic Relations District Court law, and upon
[ ] a petition of [ ] a motion of ....................................................................................................................................... or [ ] the Court’s own motion,
a hearing has been held, notice has been given as prescribed by law, and the Court has found it necessary to protect the child’s life,
health, safety or normal development. Therefore, the Court orders that:

9 9
LAST FIRST MIDDLE LAST FIRST MIDDLE
NAME OF PERSON SUBJECT TO ORDER NAME OF PERSON SUBJECT TO ORDER
(PARENT, GUARDIAN, LEGAL CUSTODIAN OR OTHER FAMILY OR HOUSEHOLD MEMBER) (PARENT, GUARDIAN, LEGAL CUSTODIAN OR OTHER FAMILY OR HOUSEHOLD MEMBER)

is required to observe reasonable conditions of behavior as set forth below:

[ ] 1. To abstain from offensive conduct against the child or against a family or household member of the child or against any
person to whom custody of the child is awarded.
[ ] 2. To cooperate in the provision of the following reasonable services or programs designed to protect the child’s life, health or
normal development: ............................................................................................................................................................................................................
[ ] 3. To allow ..................................................................................................................................................................... to come into the child’s home
COURT-SELECTED INVESTIGATORY ENTITY
[ ] at reasonable times selected by the investigatory entity
[ ] ...........................................................................................................................................................................................................................................
DATES AND TIMES
to visit the child and to inspect the fitness of the home and to determine the physical and emotional health of the child.
[ ] 4. To allow visitation with the child by the following persons: .................................................................................................................................
10 ......................................................................................................................................................................................................................................................
[ ] 5. To refrain from acts of commission or omission which tend to endanger the child’s life, health or normal development.
[ ] 6. To refrain from the following contacts with the child: ............................................................................................................................................
......................................................................................................................................................................................................................................................
[ ] 7. To leave the residence of the above-named child because the petitioner proved by a preponderance of the evidence that such
person’s probable future conduct would constitute a danger to the life or health of the child; and that there are no less drastic
alternatives which could reasonably and adequately protect the child’s life or health. This condition shall be in effect from
.................................................. to ................................................ and shall be reviewed by the Court on ...............................................................
TIME/DATE
[ ] 8. To grant the child possession of companion animal describe as ..........................................................................................................................
NAME/TYPE
[ ] 9. ......................................................................................................................................................................................................................................................
......................................................................................................................................................................................................................................................
11 [ ] Supplemental Sheet to Child Protective Order, DC-547, attached and incorporated by reference. No. of supplemental pages: .......... 11
NOTICE: This order will be entered into the Virginia Criminal Information Network. A motion may be filed with the court at any
time requesting a hearing to dissolve or modify this order. However, this order remains in full force and effect unless and until a
subsequent order is entered by the Court.
12 [ ] This ORDER is set for review on ...................................................................................................................... at ......................................................... .
DATE TIME
13
...................................................................... 14
______________________________________________________________________
DATE JUDGE
FORM DC-532 (MASTER, PAGE ONE OF _____) 07/14 15
Form DC-532 CHILD PROTECTIVE ORDER – Form DC-532
ABUSE AND NEGLECT

Data Elements, page one

1. Insert juvenile case number for protective order proceeding and abuse and neglect
proceeding case number.

2. Insert date of hearing at which this order is entered.

3. Insert court name.

4. Insert case name (name of child and date of birth of child on whose behalf this order is
entered).

5. Check box and fill in names of persons present at hearing.

6. Insert identifying information for person(s) to whom this order is directed.

7. Check applicable box.

8. Check applicable box and insert name of petitioner or moving party, if applicable.

9. Insert name of person(s) to whom this order is directed.

10. Check and complete conditions of behavior imposed by the judge.

11. Check box if form DC-547, SUPPLEMENTAL SHEET TO CHILD PROTECTIVE ORDER, is
attached and indicate number of supplemental pages in the field provided.

12. Check box if applicable and enter date and time for review hearing.

13. Insert date of entry of order.

14. Signature of judge.

15. Enter total number of pages in this order.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
WARNINGS TO THE PERSON(S) SUBJECT TO THIS ORDER: Case No. . . . . . . . . . . . . . .1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pursuant to Virginia Code § 18.2-308.1:4, you are prohibited from the purchase or In re: . . . . . . . . . . . . . . . . . .2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
transport of any firearm while this order is in effect. If you have a concealed handgun permit, you must immediately surrender that permit to
the court entering this order. If you violate the conditions of this order, you may be sentenced to jail and/or order to pay a fine.
FULL FAITH AND CREDIT: This order shall be enforced, even without registration, by the courts of any state, the District of Columbia, and any
U.S. Territory, and may be enforced on Tribal Lands (18 U.S.C. § 2265).
FEDERAL OFFENSES: Crossing state, territorial, or tribal boundaries to violate this order may result in federal imprisonment (18 U.S.C. § 2262).
Federal law provides penalties for possessing, transporting, shipping or receiving any firearm or ammunition while subject to a qualifying protective
order and under the circumstances specified in 18 U.S.C. § 922(g)(8).

PERSON (NO. 1) SUBJECT TO THIS ORDER: PERSON (NO. 2) SUBJECT TO THIS ORDER:
NAME . . . . . . . . . . . . . . . . . . . . . . 3
.................................................... 3
NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.................................................................................. .........................................................................................
ADDRESS . . . . . . . . . . . . . . . . .4
..................................................... 4
ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.................................................................................. .........................................................................................

5 [ ] PERSONAL SERVICE 4
TELEPHONE NO. . . . . . . . . . . . . . . . . . . . . . . . . . [5] PERSONAL SERVICE 4
TELEPHONE NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6 [ ] NOT FOUND [6] NOT FOUND

Respondent’s Description (for VCIN) Respondent’s Description (for VCIN)

RACE . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 SEX ............................ RACE . . . . . . . . . . . . . . . . . . . . . . . . . . 10 SEX ............................
DOB ........................................................................... DOB ...........................................................................
HGT . . . . . . . . . . . . . . . . . . . . . . . . . . . . WGT ........................... HGT . . . . . . . . . . . . . . . . . . . . . . . . . . . . WGT ...........................
EYES . . . . . . . . . . . . . . . . . . . . . . . . . . . HAIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . EYES . . . . . . . . . . . . . . . . . . . . . . . . . . . HAIR . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SSN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SSN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Telephone No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Telephone No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Relationship to Petitioner/Plaintiff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Relationship to Petitioner/Plaintiff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Distinguishing features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distinguishing features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PERSON AGE 12 OR OLDER PROTECTED BY ORDER: FAMILY MEMBER OF PROTECTED PERSON:
(See form DC-621, NON-DISCLOSURE ADDENDUM.) (See form DC-621, NON-DISCLOSURE ADDENDUM.)
NAME . . . . . . . . . . . . . . . . . . . . . . . .11
................................................. 12
NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5 [ ] PERSONAL SERVICE [5] PERSONAL SERVICE

6 [ ] NOT FOUND [6] NOT FOUND

_____________________________________________________________ 7 ____________________________________________________________________ 7
SERVING OFFICER SERVING OFFICER

for 8 for _____ 8

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
........................................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
............................................
DATE AND TIME DATE AND TIME
PETITIONER:
[ ] See form DC-621, NON-DISCLOSURE ADDENDUM. ____________________________________________________________________ 14
RELATIONSHIP TO PERSON PROTECTED BY ORDER
13
NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] See form DC-621, NON-DISCLOSURE ADDENDUM.
.................................................................................
15
NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..........................................................................................
[ ] PERSONAL SERVICE 5 [5] PERSONAL SERVICE
[ ] NOT FOUND [ ] NOT FOUND
6 6
7
______________________________________________________________ ___________________________________________________________________
7
SERVING OFFICER SERVING OFFICER

for 8 for ____ 8

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
...................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
...........................................
DATE AND TIME DATE AND TIME
FORM DC-532 (MASTER, PAGE TWO OF _____) 04/13 16
Form DC-532 CHILD PROTECTIVE ORDER – Form DC-532
ABUSE AND NEGLECT

Data Elements, page two

1. Insert case number.

2. Insert case name.
3. Insert name of person who is subject to the order.
4. Insert address and telephone number of person who is subject to the order.
5. Serving officer to check this box if personal service obtained.
6. Serving officer to check this box if person to be served could not be found.
7. Signature of serving officer.
8. Insert name of jurisdiction/agency. Insert name of sheriff if served by deputy sheriff.
9. Insert date and time of service.
10. Enter identifying information for respondent(s), if known.
11. Insert name of the person age 12 or older who is protected by the order. (See Using This
Form, 4.c.)
12. Insert name of the family member of the person who is protected by the order. (This may
be the person with whom the protected child lives or another family member whose
address information should not be disclosed.) (See Using This Form, 4.c.)
13. Insert the Petitioner’s name. Do not provide Petitioner’s address and telephone number.
(See Using This Form, 4.c.)
14. Insert relationship to the protected person of the person to be served.
15. Insert name of the person to be served. Do not provide person’s address and telephone
number. (See Using This Form, 4.c.)
16. Insert total number of pages in this order.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
FORM DC-533 ASSESSMENT/PAYMENT ORDER Page: 1

Using This Form

1. Copies

a. Original - to court.

b. First copy - to person ordered to pay. If more than one such person, provide additional
copies to each such person.

c. Other copies as dictated by local practice.

2. Prepared by clerk or service provider; signed by judge.

3. Attachments

a. Copy of payment instructions if provided by agency named in Data Element No. 4.

4. Preparation details

a. Data Element No. 5 - If investigation, mediation or supervised visitation is provided by

the agency described in Data Element No. 4, complete Data Elements Nos. 4 - 8.

b. Data Element No. 7 - The amount to be assessed is provided by the agency named in
Data Element No. 4.

c. Data Element No. 8 - The court may waive payment of any or the entire amount assessed.
The clerk's office does not handle these payments.

d. Data Element No. 9 - If parents are ordered to pay to the court any amount incurred for
providing court-appointed counsel for a juvenile, then Data Element No. 9 is completed
and the clerk handles this payment.

e. If a guardian ad litem has been appointed for a child in a case, Data Elements Nos. 10-14
should be completed. The clerk handles these payments.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
FORM DC-533 ASSESSMENT/PAYMENT ORDER Page: 2

ASSESSMENT/PAYMENT ORDER
Commonwealth of Virginia VA. CODE § 16.1-267, 16.1-274 Court Case No.: .............................................................1

2
.............................................. ..................................... [ ] Circuit Court
CITY OR COUNTY
[ ] Juvenile and Domestic Relations District Court
3
................................................................................ v./In re .........................................................................
PETITIONER RESPONDENT

INVESTIGATION/MEDIATION/SUPERVISED VISITATION
4
........................................................................................................... has provided the following services:
AGENCY
[ ] investigation
5 [ ] mediation
[ ] supervised visitation
Therefore, the court orders the assessment of the following fees pursuant to statutorily authorized guidelines, together with
waiver (if any) of payment of fees as shown below:
6 [ ] Petitioner
$ . . . . . . . . . . . . . . . . . . . . . . .7
. . . . . . . . . . . . . . . . . . . . . . assessed and
[ ] $. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . of payment of assessment is waived
8 [ ] no waiver of payment of assessment

6 [ ] Respondent
7
$ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . assessed and
8 ] $ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . of payment of assessment is waived
[
[ ] no waiver of payment of assessment
The agency named above shall determine the method and medium of payment.

COURT-APPOINTED ATTORNEY’S FEES

Legal counsel had been appointed to represent the juvenile in this case and the parents were informed of their liability for
the attorney’s fees. After an investigation, the court finds the parents able to pay the attorney’s fees and ORDERS payment of
such costs to this court as shown below.

$ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . to be paid by father, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
$ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . to be paid by mother, .....................................................

GUARDIAN AD LITEM COSTS FOR A CHILD

A guardian ad litem was appointed in this case and the total amount allowed to 10 ,

the guardian ad litem, was $ . . . . . . . . . . . . . . . 11

. .............

[ ] The court finds that the [ ] father [ ] mother [ ] parents .....................................................................

in whole or in part and ORDERS payment of such costs as shown below.
12
$ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . to be paid by father, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
$ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . to be paid by mother, .....................................................

$ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . to be paid by ................................................................
14[ ] The court finds that the [ ] father [ ] mother [ ] parents [ ] ............................................ is/are unable to pay.
15
........................................................ ________________________________________________________ 16
DATE JUDGE
FORM DC-533 MASTER 10/06

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
FORM DC-533 ASSESSMENT/PAYMENT ORDER Page: 3

Data Elements

1. Court case number.

2. Court name.

3. Case name.

4. Name of agency if providing services described in Data Element No. 5.

5. Type of services provided by agency named in Data Element No. 4.

6. Check type of party against whom costs will be assessed.

7. Amount of costs assessed against the type of party above this line.

8. Check the appropriate box and, if applicable, insert the amount of assessment for which
payment is waived.

9. If payment of attorney's fees is ordered, insert the amount to be paid by each parent and the
name of that parent.

10. If a guardian ad litem has been appointed for a child in the case, insert the guardian ad
litem’s name.

11. Amount allowed to guardian ad litem.

12. Check box if court finds parent(s) or party with a legitimate interest in the child is/are able to
pay and check applicable box(es) to indicate who shall pay.

13. Amounts to be paid by each parent or party with a legitimate interest in the child and the
name of that parent.

14. Check if court finds a parent(s) or party with a legitimate interest in the child is/are unable to
pay and check applicable box(es) to indicate who is unable to pay.

15. Date of entry of order.

16. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-534 ORDER FOR VOLUNTARY TERMINATION OF Form DC-534
RESIDUAL PARENTAL RIGHTS

Using This Form

1. Copies – Note: This is a master form. Copies must be made for use.

a. Original - to court.

b. First copy - to parents.

c. Second copy - to person or entity granted custody.

d. Additional copies as dictated by local practice.

2. Prepared by clerk, signed by judge.

3. Attachments - Form DC-535, NOTICE OF TERMINATION OF RESIDUAL PARENTAL RIGHTS

4. Preparation Details

a. This form is used only when residual parental rights are terminated voluntarily
pursuant to an entrustment agreement or other voluntary relinquishment by
parents.

b. This form should not be used if the court does not terminate parental rights.

c. Data Element Nos. 1-10 on page one should always be completed.

d. Data Element Nos. 11-15 OR Data Element No. 16 should be filled out based on
the circumstances of the case.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
ORDER FOR VOLUNTARY TERMINATION OF 1
Case No. ......................................................................
RESIDUAL PARENTAL RIGHTS
Commonwealth of Virginia VA. CODE §§ 16.1-277.01, 16.1-277.02, 16.1-278.3, 16.1-283 2
.........................................................................................
DATE OF HEARING

[ ] Circuit Court
3
............................................................................................................................................ [ ] Juvenile and Domestic Relations District Court
In re:
4
................................................................................................................................... 5
..................................................................................................
NAME OF CHILD DATE OF BIRTH

6
................................................................................................................. 7
...................................................................................................................
FATHER MOTHER

8
This case was brought upon a petition by ....................................................................................................... which alleges that the child
comes within the jurisdiction of the Juvenile and Domestic Relations District Court law. The parties were informed by the Court
of their right to representation by a lawyer.
9
...................................................................................................................................... was appointed by the Court as guardian ad litem for the child.
NAME OF ATTORNEY

10 [ ] If no summons or notification is required pursuant to Virginia Code § 16.1-263, I, the undersigned judge, certify that the
identity of the [ ] father [ ] mother [ ] guardian is not reasonably ascertainable.
1. Having heard the evidence and having determined that the child is within the jurisdiction of this Court, the Court finds that:
11
[ ] Father [ ] mother voluntarily entered into an entrustment agreement relinquishing the custody of the child to
12
.................................................................................................................................................. in order that the child be placed for adoption.
PUBLIC OR PRIVATE CHILD-PLACING AGENCY

The Court finds, based upon clear and convincing evidence, that the agreement is in the best interest of the child, and
the Court approves the entrustment agreement.

13[ ] The ....................................................................................................................................................... has filed a foster care plan pursuant to

PUBLIC OR PRIVATE CHILD-PLACING AGENCY
Virginia Code § 16.1-281.

14[ ] Even though [ ] father [ ] mother, the remaining parent, has not entered into the entrustment agreement, the Court
finds, based upon clear and convincing evidence, that the agreement is in the best interest of the child and the Court
further finds that
[ ] the identity of the remaining parent is not reasonably ascertainable; or
[ ] the identity and whereabouts of the remaining parent are known and reasonably ascertainable, and the remaining
parent was served in person or by substituted service with notice of the termination proceeding pursuant to Virginia
Code § 8.01-296 or § 16.1-264; or
[ ] the whereabouts of the remaining parent are not reasonably ascertainable and the remaining parent was given notice
15 of the termination proceeding:
[ ] by certified or registered mail at the last known address and the remaining parent failed to object to the
proceeding within 15 days of the mailing of such notice, or
[ ] through an order of publication, published at least once per week in a newspaper having general circulation in
the area for a period of 4 weeks, and the remaining parent fails to object to the proceeding.

16 [ ] Father [ ] mother seek to be relieved of the care and custody of the child, terminate residual parental rights and
authorize the placement of the child for adoption.

FORM DC-534 (MASTER, PAGE ONE OF TWO) 07/14

Form DC-534 ORDER FOR VOLUNTARY TERMINATION OF Form DC-534
RESIDUAL PARENTAL RIGHTS

Data Elements, page one

1. Insert court case number.

2. Insert date of hearing.

3. Insert court name. Check box for appropriate court.

4. Insert name of child who is the subject of petition.

5. Insert date of birth of child.

6. Insert name of father.

7. Insert name of mother.

8. Insert name of petitioner.

9. Insert name of attorney appointed as guardian ad litem.

10. Check box if applicable. Then check the box corresponding to the person whose identity
cannot be ascertained.

11. Check the applicable box(es).

12. Insert name of agency to which custody of the child was entrusted.

13. Check to document that a foster care plan documenting termination as being in the best
interest of the child has been filed. Insert the name of the agency which produced the
report.

14. Check if applicable and check one of two boxes to indicate which parent did not enter
into the entrustment agreement.

15. If Data Element No. 14 is checked, check the appropriate boxes.

16. Check the applicable box(es).

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
AND, based upon clear and convincing evidence, it is in the child’s best interest that the residual parental rights of the
1 [ ] father [ ] mother be terminated.
2. The Court ORDERS that the residual parental rights of

2
..............................................................................................................................................................................................................................................
NAME(S) OF PARENT(S)
which include, but are not limited to, the right of visitation, consent to adoption and right to determine religious affiliation
be terminated. If the child is the subject of an entrustment agreement, this order renders the approved entrustment
agreement irrevocable, in accordance with the provisions of Virginia Code § 16.1-227.01.

3. Upon a finding that there is no less drastic alternative to transferring legal custody of the child, the child is

3
committed to the care and custody of ....................................................................................................................................................................
PUBLIC OR PRIVATE CHILD-PLACING AGENCY OR INDIVIDUAL / ADDRESS

a. [ ] If the child is committed to the care and custody of a local board of social services, it has been further found
that reasonable efforts [ ] have [ ] have not been made to prevent removal and that continued placement in
4 the home is contrary to the welfare of the child.

b. [ ] Other: .....................................................................................................................................................................................................

5 4. [ ] The Court further ORDERS that the board or agency shall have the authority to place the child for adoption and
consent thereto, shall make permanent plans for the placement of the child, and shall file an Adoption Progress Report
6
pursuant to Virginia Code § 16.1-277.01 E, § 16.1-277.02 D or § 16.1-278.3 E on ...................................................................
DATE

5. 7
Other: ................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

6. [ ] This order having been entered in the 8

.......................................................................... Circuit Court, the matter is referred
CITY OR COUNTY

pursuant to Virginia Code § 16.1-297 to the ......................................................................... Juvenile and Domestic Relations
CITY OR COUNTY
District Court for further proceedings.

This ORDER is final.

9
....................................................................................... 10
_____________________________________________________________
DATE JUDGE

FORM DC-534 (MASTER, PAGE TWO OF TWO) 7/00

Form DC-534 ORDER FOR VOLUNTARY TERMINATION OF Form DC-534
RESIDUAL PARENTAL RIGHTS

Data Elements, page two

1. Check the applicable box (es).

2. Insert name of parent(s) whose rights is/are being terminated.

3. Insert name of person or entity to whom the court granted custody.

4. Check the applicable boxes if committed to a local board of public welfare or social
services. One box in either a. and b. must be checked.

5. Check this box if the agency is given permission by the court to place the child for
adoption after a final order has been entered.

6. Insert date on which the adoption progress report is due.

7. Complete if there are additional provisions.

8. If order is being entered by the Circuit Court and the case is being remanded to the
juvenile and domestic relations district court, check box and insert the name of the
locality(ies) of the involved courts.

9. Insert date of entry of order.

10. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
Form DC-535 NOTICE OF TERMINATION OF Form DC-535
RESIDUAL PARENTAL RIGHTS

Using This Form

1. Copies – this is a master form and may be photocopied as local needs dictate.

a. Original – to court.

b. Copies to parties listed in Data Element No. 4.

c. Other copies as dictated by local practice.

2. Prepared by clerk.

3. Attachments

a. Form DC-510, SUMMONS (Juvenile and Domestic Relations District Court).

b. Form DC-512, NOTICE OF HEARING.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
NOTICE OF TERMINATION OF RESIDUAL PARENTAL RIGHTS
COMMONWEALTH OF VIRGINIA VA. CODE ANN. § 16.1-283(A) CASE NO.
1
...................................................

2
............................................................................................................................................. Juvenile and Domestic Relations District Court

In re:

3
.............................................................................................................................................

TO:
4
.................................................................................................................................................................................................................................................................
PARENT, GUARDIAN, LEGAL CUSTODIAN

The attached petition seeks to terminate the residual

parental rights of the parents of the above-named
child. “Residual parental rights and responsibilities”
mean all rights and responsibilities remaining with the
parent after the transfer of legal custody or
guardianship of the person, including but not limited
to the right of visitation, consent to adoption, the right
to determine religious affiliation and the responsibility
for support.

5
........................................................................ 6
_______________________________________________________________
DATE CLERK

NOTICE OF TERMINATION OF RESIDUAL PARENTAL RIGHTS

(ATTACH TO SUMMONS OR NOTICE)

FORM DC-535 (MASTER) 6/06 CASE NO. 1

........................................................
Form DC-535 NOTICE OF TERMINATION OF Form DC-535
RESIDUAL PARENTAL RIGHTS

Data Elements

1. Court case number.

2. Court name.

3. Case name (name of subject or petition).

4. Persons to whom this notice is directed.

5. Date of issuance.

6. Signature of clerk issuing this notice.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-538 PLACEMENT ORDER Form DC-538

Using This Form

1. Copies

a. Top copy – to court.

b. Second copy – to jail.

2. Prepared by district court clerk, judge or intake officer.

3. Attachments – none.

4. Preparation details – do not use this Order to commit a juvenile to jail. Instead use form
DC-352, COMMITMENT ORDER, and observe the provisions of Va. Code §§ 16.1-249 and
16.1-284.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2008
PLACEMENT ORDER Case No. 1
.........................................................................................................................
Commonwealth of Virginia
Intake Case Number: 2
............................................................................................

3
DJJ Juvenile Number: ..........................................................................................

5 [ ] Juvenile and Domestic Relations District Court

4
.............................................................................................................................. [ ] Circuit Court

JUVENILE 6
................................................................................................................................................................................................................................

ADDRESS 7
.................................................................................................................................................................................................................................

8
SSN: .............................................................................................. 9
DATE OF BIRTH: ........................................................................................
11
AGE 10
.............................................. SEX: [ ] MALE [ ] FEMALE 12
RACE ................................................................
CHARGE: 13
....................................................................................................................................................................................................................................

........................................................................................................................................................................................................................ (continued on reverse)

14 [ ] PLACEMENT IN: [ ] Shelter Care [ ] Detention Facility

15
PENDING [ ] Hearing (see reverse) [ ] Transfer (see reverse) [ ] Other
..............................................................................................................................................................................................................................................................

16
..............................................................................................................................................................................................................................................................

HEARING DATE AND TIME (IF APPLICABLE) HEARING LOCATION (IF APPLICABLE)

17
..................................................................................................................... 18
......................................................................................................................

TO THE DIRECTOR OR SUPERINTENDENT of: 19

..............................................................................................................................

You are hereby commanded to take the above-named juvenile into your custody in accordance
with the appropriate instructions on the back of this form.

20
........................................................................ 21
______________________________________________________________________
DATE [ ] JUDGE [ ] DISTRICT COURT CLERK [ ] INTAKE OFFICER [ ] MAGISTRATE

Received 22
.................................................................................... by 23
______________________________________________________________
DATE AND TIME

FORM DC-538 (MASTER, PAGE ONE OF TWO) 05/08

Form DC-538 PLACEMENT ORDER Form DC-538

Data Elements

1. Court case number. 18. Hearing location (street address) (if

known at time of preparation of this
2. Intake case number. form).

3. Department of Juvenile Justice’s 19. Name of detention or shelter care

juvenile number. facility.

4. Name of jurisdiction of the court in 20. Dave of issuance of this Order.

which this case will be heard.
21. Signature of person issuing this
5. Check the box to show to which Order. Check the appropriate title
court the case is returnable. box below the signature line.

6. Juvenile’s name. 22. Date that juvenile is received at

facility (added by detention or
7. Street address of residence of shelter care facility personnel).
juvenile.
23. Signature of person receiving the
8. Social security number of juvenile. juvenile at facility.

9. Date of birth of juvenile.

10. Age of juvenile (in years).

11. Sex of juvenile.

12. Race of juvenile.

13. Charges placed against juvenile.

14. Check the type of facility in which

the juvenile is to be placed.

15. Check the reason for placement. If

“other” is checked, give specific
reasons.

16. Additional instructions or

information for the detention or
shelter care facility (on reverse side).

17. Hearing date and time (if known at

time of preparation of this form).

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2008
INSTRUCTIONS

If the Juvenile is placed:

PENDING HEARING – Hold the Juvenile in your custody pending such hearing until the date and time
shown, unless otherwise directed by the Court.

PENDING TRANSFER – Hold the Juvenile in your custody pending transfer of the Juvenile to the local
board of social services or the Department of Juvenile Justice as ordered by Court.

FORM DC-538 (MASTER, PAGE TWO OF TWO) 05/08

Form DC-539 RELEASE ORDER Form DC-539

Using This Form

1. Copies

a. Top copy – to court.

b. Second copy – to jail.

2. Prepared by district court clerk, judge or intake officer.

3. Attachments – none.

4. Preparation details

a. This form is intended for use in pre-adjudication detention.

b. Do not use this form if the child was detained in jail. Instead, use district court
form DC-353, RELEASE ORDER.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
RELEASE ORDER Case No. 1
............................................................................................

(JUVENILE) Intake Case Number:. . . . . . . . . . . .2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DJJ Juvenile Number: . . . . . . . . . .3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5 [ ] Juvenile and Domestic Relations District Court

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
.................................................. [ ] Circuit Court
JURISDICTION

JUVENILE 6
...............................................................................................................................................................

ADDRESS 7
...............................................................................................................................................................

....................................................................................................................................................................................

SSN: . . . . . . . . . . . . . . . . . . . . . . . . . . . .8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATE OF BIRTH: 9

............................................................................
11
AGE . . . . . . . . . . . . . . . . . . . . . . . . . 10
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SEX: [ ] MALE [ ] FEMALE RACE: . . . . . . . . . . . 12
.........................

CHARGE: 13
.................................................................................................................................................................

....................................................................................................................................................................................

14
[ ] RELEASE FROM: [ ] Shelter Care [ ] Detention Facility
....................................................................................................................................................................................
15
....................................................................................................................................................................................

TO THE DIRECTOR OR SUPERINTENDENT of: 16

...............................................................................................

Release forthwith the above-named Juvenile if detained for no other cause than the commitment dated:
17
........................................................................
DATE OF COMMITMENT

18
........................................................................ 19
_____________________________________________
DATE [ ] JUDGE [ ] CLERK [ ] PROBATION DEPT.

ADDITIONAL REMARKS: 20
....................................................................................................................................

....................................................................................................................................................................................

Released 21
....................................................... 22
AM/PM by __________________________________________
DATE AND TIME

FORM DC-539 MASTER 11/07

Form DC-539 RELEASE ORDER Form DC-539

Data Elements

1. Court case number.

2. Intake case number.

3. Department of Juvenile Justice’s Juvenile number.

4. Name of jurisdiction of the court in which this case will be heard.

5. Check the box to show to which court the case is returnable.

6. Juvenile’s name.

7. Street address of residence of juvenile.

8. Social security number of juvenile.

9. Date of birth of juvenile.

10. Age of juvenile (in years).

11. Sex of juvenile.

12. Race of juvenile.

13. Charges placed against juvenile.

14. Check the type of facility from which juvenile is to be released.

15. Additional instructions or information for the detention or shelter care facility.

16. Name of detention or shelter care facility.

17. Date on which juvenile was committed to the facility.

18. Date of issuance of this order.

19. Signature of person issuing Release Order. Check the appropriate title box below the
signature line.

20. Additional remarks or instructions.

21. Date of release from facility (added by shelter care or detention facility personnel).

22. Signature of person releasing juvenile at facility.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-542 ORDER FOR INVESTIGATION AND REPORT Form DC-542

Using This Form

1. Copies

a. Original – to court.

b. First copy – to person or agency conducting investigation.

c. Other copies as local practice dictates.

2. Prepared by judge.

3. Attachments – Copies of appropriate case papers as determined by judge to provide

information needed to respond to Data Element No. 6.

4. Preparation details

a. In Data Element No. 6, the blank space is used to specify additional matters to be
investigated in non-delinquency matters as dictated by the circumstances of the
case.

b. Use Data Element No. 10 to order additional provisions affecting the investigation
as needed, such as requiring the child’s custodian to permit the investigator to
interview the child.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
ORDER FOR INVESTIGATION AND REPORT Case No. 1
....................................................................................
Commonwealth of Virginia VA. CODE §§ 16.1-237(A), 16.1-269.1, 16.1-273

The above-named child is before this court on a petition:

[ ] To determine the custody of the child

[ ] Alleging that the child is in need of services or in need of supervision
4
[ ] Alleging delinquency
[ ] Other: ...............................................................................................................................................................................................................................
To aid the court in this case, the court ORDERS

[ ] Court Service Unit

5 [ ] Department of Social Services
[ ] ..............................................................................................................................................................................................................................................

to investigate and file a written report concerning a social history of the physical, mental and social conditions and
personality of the child and the following factors concerning the child:

[ ] The facts and circumstances surrounding the violation of law (adjudication in this case having been made).
[ ] For a transfer hearing, the statutory factors as specified in Virginia Code § 16.1-269.1(A)(4).
6
[ ] An assessment of any affiliation with a youth gang as defined in Virginia Code § 16.1-299.2.
[ ] 6
..............................................................................................................................................................................................................................................

7[ ] The court ORDERS that a drug screening be completed and if the screening indicates that the juvenile has a
substance abuse or dependence problem, an assessment shall be completed pursuant to Virginia Code § 16.1-273.
The court further ORDERS that this report be filed with the clerk of this court on or before 8
..........................................................;

the time set by the court for hearing the matter is 9

........................................................................................................
DATE AND TIME OF HEARING

10 [ ] The court further ORDERS: .....................................................................................................................................................................................

11
....................................................................................... 12
________________________________________________________
DATE OF ORDER JUDGE

FORM DC-542 MASTER 10/14

Form DC-542 ORDER FOR INVESTIGATION AND REPORT Form DC-542

Data Elements

1. Insert court case number.

2. Insert name of court.

3. Insert case name (name of child).

4. Insert reason for which child is in court.

5. Insert name of person or agency ordered to conduct investigation.

6. Insert type of information which is to be obtained through investigation. See Using This
Form, 4(a).

7. Check if court orders drug screening pursuant to Virginia Code § 16.1-273.

8. Insert date by which the investigation report is to be filed.

9. Insert date of next hearing in this case.

10. Insert additional provisions of the order. See Using This Form, 4(b).

11. Insert date on which investigation ordered.

12. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
Form DC-543 CONFIDENTIALITY NOTICE Page: 1

Using This Form

1. Copies – to each copy of a report prepared to Va. Code §§ 16.1-237(A) or 16.1-273 and
distributed to attorneys in the case.

2. Preparation – none.

3. Attachments – see No. 1, above.

4. Preparation details – none.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-543 CONFIDENTIALITY NOTICE Page: 2

CONFIDENTIALITY NOTICE

Notice to Persons Receiving Reports or Amended Reports

Virginia Code § 16.1-274 and Rule 8:5 of the Rules of the Supreme Court of Virginia
require that all parties or attorneys who receive a copy of any social, medical, psychiatric or
psychological records and reports, including predisposition studies, or amended reports shall
return said report to the clerk upon the conclusion of the hearing "and shall not make copies of
such report or amended report or any portion thereof."

Virginia Code § 16.1-305 provides that all such records and reports are available for
inspection only by certain designated persons, including the parties to the proceeding and their
attorneys. Because matters contained in these records or reports are confidential and sensitive in
nature, the contents of said reports shall not be divulged to unauthorized persons.

FORM DC-543 MASTER 10/07

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
DC-544 ORDER FOR COURT -APPOINTED DC-544
SPECIAL ADVOCATE (CASA)

Using This Form

1. Copies

a. Original--to the court.

b. First copy--to court-appointed special advocate (CASA).

c. Second copy--to child’s guardian ad litem if one is appointed.

d. Third copy--to each entity whose records related to the child the court-appointed special
advocate seeks to inspect or copy.

e. Additional copies as dictated by local practices.

2. Prepared for and signed by judge.

3. Attachments--none.

4. Preparation details - The copy of the order presented by the court-appointed special advocate is
not required by law to be a certified copy. If requested, a certified copy should be provided.
Such certification should comply with Va. Code '' 8.01-391(B) and 16.1-69.40.

DISTRICT COURT MANUAL FORMS VOLUME

MAY 2003
ORDER FOR COURT-APPOINTED Case No.: . . . . . . . . . . . . . . . . . . . . . . .1
..............................
SPECIAL ADVOCATE (CASA)
Commonwealth of Virginia
Va. Code §§ 9.1-153 through 9.1-157

2
................................................... ................................................. Juvenile and Domestic Relations District Court

In re: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , a child

4
............................................................ is hereby appointed as the court-appointed special advocate (CASA) in this case.

Pursuant to Sections 9.1-153 et seq. of the Code of Virginia, the CASA shall:

1. Investigate this case to provide independent factual information to the court.

2. Submit to the court a written report of the investigation in compliance with statutory provisions regarding such reports.
The written report shall include recommendations as to the child’s welfare.
3. Monitor this case to ensure compliance with this court’s orders, including observing the child in his or her placement.
4. Assist the guardian ad litem’s representation of the child’s needs and best interests, if a guardian ad litem has been
appointed in this case.
5. ..................................................................................................................................................................
..................................................................................................................................................................
5
................................................................... ..............................................................................................
..................................................................................................................................................................
..................................................................................................................................................................

It is therefore ORDERED, pursuant to Virginia Code § 9.1-156, that the Court’s files with respect to this case shall be open for
inspection and copying by the assigned CASA and the Staff in the CASA program.

All state and local departments, agencies, authorities and institutions are to assist and cooperate with the CASA in performance of his
or her duties.

The following person(s) are ORDERED to cooperate with the CASA to monitor the compliance with any orders from this court.
6
....................................................................................................................................................................................

....................................................................................................................................................................................

Upon presentation by the CASA of a copy of this Order, any state or local agency, department, authority or institution, and any
hospital, school, physician or other health or mental health care provider shall permit the CASA to inspect and copy, without the
consent of the child or his parents, any records relating to the child in this case.

7 [ ] In lieu of the CASA inspecting and copying any related records of the child involved, the mental health care provider shall be
available within 72 hours to conduct for the CASA a review and interpretation of the child’s treatment records which are
specifically related to the investigation.

Pursuant to Virginia Code § 9.1-156, a CASA shall not disclose the content of any document or record to which the CASA may
become privy, which is otherwise confidential pursuant to provisions of the Code of Virginia, except upon order of a court of
competent jurisdiction.

8
.........................................................
9
_____________________________________________
DATE JUDGE

NOTICE:
A CASA is required to report suspected abuse or neglect of a child pursuant to Virginia Code §§ 63.2-1509 and 9.1-153.

FORM DC-544 (MASTER) REVISED 05/03

DC-544 ORDER FOR COURT -APPOINTED DC-544
SPECIAL ADVOCATE (CASA)

Data Elements

1. Court case number.

2. Court name.

3. Name of child.

4. Name of court-appointed special advocate (CASA).

5. Other duties of the CASA.

6. Identify any other persons ordered by the court to cooperate with the CASA .

7. Check box if mental health care provider is to be available to CASA to review and interpret
treatment records, in lieu of copying records.

8. Date of signing of order.

9. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

MAY 2003
Form DC-545 PRELIMINARY CHILD PROTECTIVE ORDER Form DC-545

Using This Form

1. Copies
a. Original – to court.

b. Copy – to parent or other person listed in Data Element No. 6, page one.

c. Copy – to parent if different from individual referred to in b., above.

d. Copy – investigatory entity named in paragraph number 3 on page one of form.

e. Copy – to person protected by order.

f. Copy – to family member of protected person.

g. Copy – to the local law enforcement agency for service of process.

2. Prepared by clerk, signed by judge.

3. Attachments

a. Form DC-510, SUMMONS, if issued when the PRELIMINARY CHILD PROTECTIVE ORDEr is
entered.

b. Form DC-621, NON-DISCLOSURE ADDENDUM, for person age 12 or older who is protected by
the order, a family member of the protected person and others as appropriate.

c. Form DC-511, JUVENILE PETITION; adult criminal warrant; or written motion, if any.

d. Form DC-547, SUPPLEMENTAL SHEET FOR CHILD PROTECTIVE ORDER, if used.

e. AFFIDAVIT (if used).

4. Preparation details

a. This form does not have to be used with any other preprinted form; however, the affidavit
should be attached only to the original order if an affidavit is used in the ex parte
proceeding.

b. This form can accommodate two respondents where the conditions are the same and the same
child is being protected.

c. If statement of conditions (Data Element No. 13, page one and Data Element Nos. 2 and 3,
page two) exceed the space allotted, use form DC-547, SUPPLEMENTAL SHEET FOR CHILD
PROTECTIVE ORDER.

d. With page two, complete form DC-621, NON-DISCLOSURE ADDENDUM, for the person age
12 or older who is protected by the order, the family member of the protected person and, as
appropriate, for the petitioner and any other person whose address information should not be
disclosed.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
PRELIMINARY CHILD PROTECTIVE ORDER Juvenile Case No. . . . . . . . . . . . . .1
..................................
Commonwealth of Virginia Va. Code § 16.1-253
2
........................................................................
DATE OF HEARING

3
.................................................................................................................... Juvenile and Domestic Relations District Court
In re: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
.................................................... 5
..................................................................
NAME OF CHILD DATE OF BIRTH
Present:
[ ] Mother . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Mother’s attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
[ ] Father . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Father’s attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6 [ ] Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Guardian ad litem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
[ ] Agency Representative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Agency attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
[ ] Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] CASA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
COMPLETE DATA BELOW IF KNOWN COMPLETE DATA BELOW IF KNOWN
DESCRIPTION OF PERSON (No. 1) SUBJECT TO THIS ORDER DESCRIPTION OF PERSON (No. 2) SUBJECT TO THIS ORDER

NAME: 7 NAME: 7
RACE SEX BORN HT. WGT. EYES HAIR RACE SEX BORN HT. WGT. EYES HAIR
MO. DAY YR. FT. IN. MO. DAY YR. FT. IN.

SSN SSN

It appearing that the above-named child is within the purview of the Juvenile and Domestic Relations District Court law, and upon
8 [ ] a petition of [ ] a motion of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or [ ] the Court’s own motion,
9 [ ] In an ex parte proceeding, based on a petition/motion supported by [ ] an affidavit [ ] sworn testimony before the judge or
intake officer, it is established the child may be subject to an imminent threat to life or health to the extent that delay for the
provision of an adversary hearing would be likely to result in serious or irremediable injury to the child’s life or health.
OR 10
11 [ ] After an adversary hearing following notice given in a manner prescribed by law, the court finds it necessary to protect the
child’s life, health, safety or normal development pending the final determination of a matter before the court.
THEREFORE, the Court orders that:

12 12
LAST FIRST MIDDLE LAST FIRST MIDDLE
NAME OF PERSON (NO. 1) SUBJECT TO ORDER NAME OF PERSON (NO. 2) SUBJECT TO ORDER
(PARENT, GUARDIAN, LEGAL CUSTODIAN OR OTHER FAMILY OR HOUSEHOLD MEMBER) (PARENT, GUARDIAN, LEGAL CUSTODIAN OR OTHER FAMILY OR HOUSEHOLD MEMBER)

is/are required to observe reasonable conditions of behavior as set forth below:

13 to visit the child and to inspect the fitness of the home and to determine the physical and emotional health of the child.
[ ] 4. To allow visitation with the child by the following persons: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......................................................................................................................................................................
[ ] 5. To refrain from acts of commission or omission which tend to endanger the child’s life, health or normal development.
[ ] 6. To refrain from the following contacts with the child: .............................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
[ ] To leave the residence of the above-named child because the petitioner proved by a preponderance of the evidence that
such person’s probable future conduct would constitute a danger to the life or health of the child; and that there are no
less drastic alternatives which could reasonably and adequately protect the child’s life or health pending a final
determination on the petition.
FORM DC-545 (MASTER, PAGE ONE OF _____) 04/13 14
Form DC-545 PRELIMINARY CHILD PROTECTIVE ORDER Form DC-545

Data Elements, page one

1. Court case number.

2. Insert date of hearing at which this order is entered.

3. Insert court name.

4. Insert case name (name of child who is the subject of a petition or motion).

5. Insert child’s date of birth.

6. Check box and fill in name of persons present for the hearing.

7. Insert identifying information for person(s) to whom this order is directed.

8. Check applicable box and insert name of petitioner or moving party, if applicable.

9. Check this box if this order was issued after an ex parte hearing.

10. If Data Element No. 8 is checked, check the appropriate box to show what type of
supporting evidence was presented.

11. Check this box if this order was issued after an adversary hearing.

12. Name(s) of person(s) who is(are) the subject of this order.

13. Check box(es) and complete condition(s) of behavior imposed by the judge.

14. Insert total number of pages in this order.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
1
Case No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2[ ] 7. To grant the child possession of the companion animal described as . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NAME /TYPE

3[ ] 8. ......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................

4[ ] Supplemental Sheet to Child Protective Order, DC-547, attached and incorporated by reference. No. of supplemental pages: . .4
...

5 [ ] Ex Parte Proceedings Only: It is further ORDERED that a preliminary protective order hearing be held at this court
on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . and
that the parents, guardian, legal custodian, other person standing in loco parentis to the child, the family or household member
named above, and the child if he or she is 12 years of age or older be given notice of this hearing.
6 [ ] No affidavit filed. The basis upon which this order is entered, including a summary of the allegations made and the Court’s
findings, is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
............................................................................................................................................................................
............................................................................................................................................................................
............................................................................................................................................................................
............................................................................................................................................................................

The specific factual circumstances necessitating the issuance of this order are: . . . . . . . .7
.................................................................
..................................................................................................................................................................................
..................................................................................................................................................................................
..................................................................................................................................................................................

WARNINGS TO THE PERSON(S) SUBJECT TO THIS ORDER:

This order will be entered into the Virginia Criminal Information Network. A motion may be filed with the court at any time requesting
a hearing to dissolve or modify this order. However, this order remains in full force and effect unless and until a subsequent order or the
dispositional order is entered by the Court. Only the Court can change this order.

FULL FAITH AND CREDIT: If this order was issued after an adversarial hearing, this order shall be enforced, even without
registration, by the courts of any state, the District of Columbia, and any U.S. Territory, and may be enforced on Tribal Lands
(18 U.S.C. § 2265).

FEDERAL OFFENSES: Crossing state, territorial, or tribal boundaries to violate this order may result in federal imprisonment
(18 U.S.C. § 2262). Federal law provides penalties for possessing, transporting, shipping or receiving any firearm or ammunition while
subject to a qualifying protective order and under the circumstances specified in 18 U.S.C. § 922(g)(8).

8 [ ] This ORDER is set for review on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATE TIME

9
............................................................ _____________________________________________________________ 10
DATE JUDGE

FORM DC-545 (MASTER, PAGE TWO OF _____) 07/14

11
Form DC-545 PRELIMINARY CHILD PROTECTIVE ORDER Form DC-545

Data Elements, page two

1. Insert court case number.

2. Check box, if applicable, and insert description (including name and type, if known) of
companion animal.

3. Check box, if applicable and insert other orders of the Court.

4. Check box if form DC-547, SUPPLEMENTAL TO CHILD PROTECTIVE ORDER, is attached

and indicate number of supplemental pages in field provided.

5. If this order is issued after an ex parte hearing, check box and insert date and time for
adversary hearing.

6. Check box and provide basis upon which order is entered when entered pursuant to an ex
parte proceeding and no affidavit is provided.

7. Insert facts justifying the issuance of the preliminary protective order (required for using
order as part of notice for the adversary hearing).

8. If applicable, check box and insert date and time for review hearing.

9. Insert date of entry of order.

10. Signature of judge.

11. Insert total number of pages in this order.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
RETURNS: Each person was served according to law, as indicated Case No. . . . . . . . . . . . .1
..............................................
below, unless not found.
In re: . . . . . . . . . . . . . . . . .2
..............................................
PERSON (NO. 1) SUBJECT TO THIS ORDER: PERSON (NO. 2) SUBJECT TO THIS ORDER:
3
NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.................................................................................. .........................................................................................

4
ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.................................................................................. .........................................................................................

5
[ ] PERSONAL SERVICE 4
TELEPHONE NO. . . . . . . . . . . . . . . . . . . . . . . . . .
5[ ] PERSONAL SERVICE 4
TELEPHONE NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6 [ ] NOT FOUND 6[ ] NOT FOUND

____________________________________________________________ 7 7
______________________________________________________________
SERVING OFFICER SERVING OFFICER
for __________________________________________________________ 8 8
for _______________________________________________________________

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
..................................... .......................................................9
.................................................
DATE AND TIME DATE AND TIME

Respondent’s Description (for VCIN)

10 Respondent’s Description (for VCIN)
10
RACE . . . . . . . . . . . . . . . . . . . . . . . . . . . SEX ............................ RACE . . . . . . . . . . . . . . . . . . . . . . . . . . SEX ............................
DOB ........................................................................... DOB ...........................................................................
HGT . . . . . . . . . . . . . . . . . . . . . . . . . . . . WGT ........................... HGT . . . . . . . . . . . . . . . . . . . . . . . . . . . . WGT ...........................
EYES . . . . . . . . . . . . . . . . . . . . . . . . . . . HAIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . EYES . . . . . . . . . . . . . . . . . . . . . . . . . . . HAIR . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SSN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SSN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Telephone No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Telephone No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Relationship to Petitioner/Plaintiff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Relationship to Petitioner/Plaintiff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Distinguishing features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distinguishing features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PERSON AGE 12 OR OLDER PROTECTED BY ORDER: FAMILY MEMBER OF PROTECTED PERSON:
(See form DC-621, NON-DISCLOSURE ADDENDUM.) (See form DC-621, NON-DISCLOSURE ADDENDUM.)
11
NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

[ ] PERSONAL SERVICE
5 5[ ] PERSONAL SERVICE

6 [ ] NOT FOUND
6[ ] NOT FOUND

_____________________________________________________________ 7 ____________________________________________________________________ 7
SERVING OFFICER SERVING OFFICER

for 8 for _____ 8

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
..................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
............................................
DATE AND TIME DATE AND TIME

PETITIONER:
[ ] See form DC-621, NON-DISCLOSURE ADDENDUM. ____________________________________________________________________ 14
RELATIONSHIP TO PERSON PROTECTED BY ORDER

13
NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] See form DC-621, NON-DISCLOSURE ADDENDUM.

.................................................................................
15
NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

..........................................................................................

5 [ ] PERSONAL SERVICE 5[ ] PERSONAL SERVICE

6 [ ] NOT FOUND 6[ ] NOT FOUND

______________________________________________________________ 7 ___________________________________________________________________ 7
SERVING OFFICER SERVING OFFICER

for 8 for ____ 8

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
...................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
..............................................
DATE AND TIME DATE AND TIME

FORM DC-545 (MASTER, PAGE THREE OF _____) 04/13 16

Form DC-545 PRELIMINARY CHILD PROTECTIVE ORDER Form DC-545

Data Elements, page three

1. Insert court case number.

2. Insert case name.

3. Insert name of person who is the subject to the order.

4. Insert address and telephone number of person who is subject to the order.

5. Serving officer to check this box if personal service obtained.

6. Serving officer to check this box if person to be served is not found.

7. Signature of serving officer.

8. Insert name of jurisdiction/agency. Insert name of sheriff if served by deputy sheriff.

9. Insert date and time of service.

10. Enter identifying information for respondent(s), if known.

11. Insert name of the person age 12 or older who is protected by the order. (See Using This
Form, 4.d.)

13. Insert the petitioner’s name. Do not provide petitioner’s address and telephone number.
(See Using This Form, 4.d.)

14. Insert relationship to the protected person of the person to be served.

15. Insert name of the person to be served. Do not provide person’s address and telephone
number. (See Using This Form, 4.d.)

16. Insert total number of pages in this order.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
Form DC-546 CHILD PROTECTIVE ORDER Form DC-546

Using This Form

1. Copies

a. Original – to court.

b. Copy – to parent or other person named in Data Element No. 9.

c. Copy – to parent if different from individual referred to in 1.b., above.

d. Copy – to investigatory entity named in paragraph 3 on page one of form.

e. Copy – to local law enforcement agency for service.

2. Prepared by clerk, signed by judge.

3. Attachments

Form DC-621, NON-DISCLOSURE ADDENDUM, for person age 12 or older who is

protected by the order, a family member of the protected person and others as
appropriate.

4. Preparation details

a. This form can accommodate two respondents where the conditions are the same
and the same child is being protected.

b. If statement of conditions on page one (Data Element No. 10, paragraph 8) exceed
the space allotted, use form DC-547, SUPPLEMENTAL SHEET TO CHILD
PROTECTIVE ORDER.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
CHILD PROTECTIVE ORDER 1
Juvenile Case No. ....................................................................
Commonwealth of Virginia Va. Code §§ 16.1-253, 16.1-277.02, 16.1-278.3
2
.........................................................................................................
DATE OF HEARING
3
.......................................................................................................................................................................... Juvenile and Domestic Relations District Court
In re: 4
................................................................................................................................................. ................................................................................................
NAME OF CHILD DATE OF BIRTH
Present:
[ ] Mother ......................................................................................... [ ] Mother’s attorney ......................................................................................
[ ] Father ........................................................................................... [ ] Father’s attorney ........................................................................................
5 [] Child .......................................................................................... [ ] Guardian ad litem ......................................................................................
[ ] Agency representative ........................................................... [ ] Agency attorney ........................................................................................
[ ] Other .......................................................................................... [ ] CASA ............................................................................................................
COMPLETE DATA BELOW IF KNOWN COMPLETE DATA BELOW IF KNOWN
DESCRIPTION OF PERSON (No. 1) SUBJECT TO THIS ORDER DESCRIPTION OF PERSON (No. 2) SUBJECT TO THIS ORDER

NAME: 6 NAME: 6
RACE SEX BORN HT. WGT. EYES HAIR RACE SEX BORN HT. WGT. EYES HAIR
MO. DAY YR. FT. IN. MO. DAY YR. FT. IN.

SSN SSN

Check if applicable:
[ ] Relationship of person No. 1 to child’s parent: [ ] child’s other parent [ ] spouse/former spouse [ ] cohabit in present or past.
7 [ ] Relationship of person No. 2 to child’s parent: [ ] child’s other parent [ ] spouse/former spouse [ ] cohabit in present or past.
It appearing that the above-named child is within the purview of the Juvenile and Domestic Relations District Court law, and upon
[ ] a petition of [ ] a motion of ....................................................................................................................................... or [ ] the Court’s own motion,
8 a hearing has been held, notice has been given as prescribed by law, and the Court has found it necessary to protect the child’s life,
health, safety or normal development. Therefore, the Court orders that:

9 9
LAST FIRST MIDDLE LAST FIRST MIDDLE
NAME OF PERSON (NO. 1) SUBJECT TO ORDER NAME OF PERSON (NO. 2) SUBJECT TO ORDER
(PARENT, GUARDIAN, LEGAL CUSTODIAN OR OTHER FAMILY OR HOUSEHOLD MEMBER) (PARENT, GUARDIAN, LEGAL CUSTODIAN OR OTHER FAMILY OR HOUSEHOLD MEMBER)

is required to observe reasonable conditions of behavior as set forth below:

[ ] 1. To abstain from offensive conduct against the child or against a family or household member of the child or against any
person to whom custody of the child is awarded.
[ ] 2. To cooperate in the provision of the following reasonable services or programs designed to protect the child’s life, health or
normal development: ............................................................................................................................................................................................................
[ ] 3. To allow ..................................................................................................................................................................... to come into the child’s home
COURT-SELECTED INVESTIGATORY ENTITY
[ ] at reasonable times selected by the investigatory entity
[ ] ...........................................................................................................................................................................................................................................
DATES AND TIMES
to visit the child and to inspect the fitness of the home and to determine the physical and emotional health of the child.
[ ] 4. To allow visitation with the child by the following persons: .................................................................................................................................
10 ......................................................................................................................................................................................................................................................
[ ] 5. To refrain from acts of commission or omission which tend to endanger the child’s life, health or normal development.
[ ] 6. To refrain from the following contacts with the child: ............................................................................................................................................
......................................................................................................................................................................................................................................................
[ ] 7. To leave the residence of the above-named child because the petitioner proved by a preponderance of the evidence that such
person’s probable future conduct would constitute a danger to the life or health of the child; and that there are no less drastic
alternatives which could reasonably and adequately protect the child’s life or health. This condition shall be in effect from
.................................................. to ................................................ and shall be reviewed by the Court on ...............................................................
TIME/DATE
[ ] 8. To grant the child possession of companion animal described as ........................................................................................................................
NAME/TYPE
[ ] 9. ......................................................................................................................................................................................................................................................
......................................................................................................................................................................................................................................................
11
11 [ ] Supplemental Sheet to Child Protective Order, DC-547, attached and incorporated by reference. No. of supplemental pages: ..........
NOTICE: This order will be entered into the Virginia Criminal Information Network. A motion may be filed with the court at any
time requesting a hearing to dissolve or modify this order. However, this order remains in full force and effect unless and until a
subsequent order is entered by the Court.
12 [ ] This ORDER is set for review on ...................................................................................................................... at ......................................................... m.
DATE TIME
13
...................................................................... 14
______________________________________________________________________
DATE
FORM DC-546 (MASTER, PAGE ONE OF _____) 07/14 15 JUDGE
Form DC-546 CHILD PROTECTIVE ORDER Form DC-546

Data Elements, page one

1. Court case number.

2. Insert date of hearing at which this order is entered.

3. Insert court name.

4. Insert case name (name of child and date of birth of child on whose behalf this order is
entered).

5. Check box and fill in name of persons present for the hearing.

6. Insert identifying information for person(s) to whom this order is directed.

7. Check applicable box.

8. Check applicable box, and insert name of petitioner or moving party, if applicable.

9. Insert name of person(s) to whom this order is directed.

10. Check and complete conditions of behavior imposed by the judge.

11. Check box if form DC-547, SUPPLEMENTAL SHEET TO CHILD PROTECTIVE ORDER, is
attached and indicate number of supplemental pages in the field provided.

12. Check box if applicable and enter date and time for review hearing.

13. Insert date of entry of order.

14. Signature of judge.

15. Insert total number of pages in this order.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
WARNINGS TO THE PERSON(S) SUBJECT TO THIS ORDER: Case No. . . . . . . . . . . .1 ...................................
If you violate the conditions of this order, you may be sentenced to jail In re: . . . . . . . . . . . . . . . .2
...................................
and/or ordered to pay a fine.
FULL FAITH AND CREDIT: This order shall be enforced, even without registration, by the courts of any state, the District of Columbia,
and any U.S. Territory, and may be enforced on Tribal Lands (18 U.S.C. § 2265).
FEDERAL OFFENSES: Crossing state, territorial, or tribal boundaries to violate this order may result in federal imprisonment
(18 U.S.C. § 2262). Federal law provides penalties for possessing, transporting, shipping or receiving any firearm or ammunition while
subject to a qualifying protective order and under the circumstances specified in 18 U.S.C. § 922(g)(8).

PERSON (NO. 1) SUBJECT TO THIS ORDER: PERSON (NO. 2) SUBJECT TO THIS ORDER:
3
NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.................................................................................. .........................................................................................

4
ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.................................................................................. .........................................................................................

[ ] PERSONAL SERVICE 4
TELEPHONE NO. . . . . . . . . . . . . . . . . . . . . . . . . . .
5[ 4
5 ] PERSONAL SERVICE TELEPHONE NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6 [ ] NOT FOUND 6[ ] NOT FOUND

____________________________________________________________ 7 ______________________________________________________________ 7
SERVING OFFICER SERVING OFFICER
for __________________________________________________________ 8 for _______________________________________________________________ 8
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
..................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
.................................................
DATE AND TIME DATE AND TIME
Respondent’s Description (for VCIN) Respondent’s Description (for VCIN)
10 10 S E X . . . . . . . . . . . . . . . . . . . . . . . . . . . .
RACE . . . . . . . . . . . . . . . . . . . . . . . . . . . SEX ............................ RACE . . . . . . . . . . . . . . . . . . . . . . . . . .
DOB ........................................................................... DOB ..........................................................................
HGT . . . . . . . . . . . . . . . . . . . . . . . . . . . . WGT ........................... HGT . . . . . . . . . . . . . . . . . . . . . . . . . . . . WGT ..........................
EYES . . . . . . . . . . . . . . . . . . . . . . . . . . . HAIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . EYES . . . . . . . . . . . . . . . . . . . . . . . . . . . HAIR . . . . . . . . . . . . . . . . . . . . . . . . . . .
SSN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SSN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Telephone No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Telephone No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Relationship to Petitioner/Plaintiff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Relationship to Petitioner/Plaintiff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Distinguishing features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distinguishing features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PERSON AGE 12 OR OLDER PROTECTED BY ORDER: FAMILY MEMBER OF PROTECTED PERSON:
(See form DC-621, NON-DISCLOSURE ADDENDUM.) (See form DC-621, NON-DISCLOSURE ADDENDUM.)
11
NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

[ ] PERSONAL SERVICE
5 5[ ] PERSONAL SERVICE
[ ] NOT FOUND
6 6[ ] NOT FOUND

_____________________________________________________________
SERVING OFFICER
7 ____________________________________________________________________
SERVING OFFICER
7
for __________________________________________________________ 8 for _______________________________________________________________ 8
................................................................................. 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
............................................
DATE AND TIME DATE AND TIME
PETITIONER:
[ ] See form DC-621, NON-DISCLOSURE ADDENDUM. ____________________________________________________________________ 14
RELATIONSHIP TO PERSON PROTECTED BY ORDER
13
NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] See form DC-621, NON-DISCLOSURE ADDENDUM.
................................................................................. 15
NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..........................................................................................
[ ] PERSONAL SERVICE
5 5[ ] PERSONAL SERVICE
6 [ ] NOT FOUND 6[ ] NOT FOUND

______________________________________________________________ 7 ___________________________________________________________________ 7
SERVING OFFICER SERVING OFFICER

for 8 for ____ 8

FORM DC-546 (MASTER, PAGE TWO OF _____) 04/13 16

Form DC-546 CHILD PROTECTIVE ORDER Form DC-546

Data Elements, page two

1. Insert court case number.

2. Insert case name.

3. Insert name of person who is the subject to the order.

4. Insert address and telephone number of person who is subject to the order.

5. Serving officer to check this box if personal service obtained.

6. Serving officer to check this box if person to be served is not found.

7. Signature of serving officer.

8. Insert name of jurisdiction/agency. Insert name of sheriff if served by deputy sheriff.

9. Insert date and time of service.

10. Enter identifying information for respondent(s), if known.

11. Insert name of the person age 12 or older who is protected by the order. (See Using This
Form, 4.c.)

13. Insert the petitioner’s name. Do not provide petitioner’s address and telephone number.
(See Using This Form, 4.c.)

14. Insert relationship to the protected person of the person to be served.

15. Insert name of the person to be served. Do not provide person’s address and telephone
number. (See Using This Form, 4.c.)

16. Insert total number of pages in this order.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2013
Form DC-547 SUPPLEMENT SHEET TO Form DC-547
CHILD PROTECTIVE ORDER

Using This Form

1. Copies

a. Original – to court.

b. Additional copies should be distributed along with copies of the associated

protective order as dictated by court procedures.

2. Preparation details

a. If statement of conditions on forms DC-527, PRELIMINARY CHILD PROTECTIVE

ORDER – ABUSE AND NEGLECT, DC-532, CHILD PROTECTIVE ORDER – ABUSE AND
NEGLECT, DC-545, PRELIMINARY CHILD PROTECTIVE ORDER, or DC-546, CHILD
PROTECTIVE ORDER exceed the space allotted, use this form to continue statement
of conditions, not form DC-653, SUPPLEMENTAL SHEET TO PROTECTIVE ORDER.

b. When the court is ordering temporary support for the children of the petitioner
and respondent in conjunction with a protective order, the form TEMPORARY
SUPPORT ORDER (now page 3 of form DC-650, PROTECTIVE ORDER – FAMILY
ABUSE) should be used, not form DC-653, SUPPLEMENTAL SHEET.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2013
SUPPLEMENTAL SHEET TO 1
Case No. ......................................................................................
CHILD PROTECTIVE ORDER
2
.........................................................................................................
DATE OF HEARING

3
In re: ............................................................................................................. 4
.........................................................................................................
NAME OF CHILD DATE OF BIRTH

5 5
NAME OF PERSON (NO. 3) SUBJECT TO ORDER NAME OF PERSON (NO. 4) SUBJECTO TO ORDER
(PARENT, GUARDIAN, LEGAL CUSTODIAN OR OTHER FAMILY OR HOUSEHOLD MEMBER) (PARENT, GUARDIAN, LEGAL CUSTODIAN OR OTHER FAMILY OR HOUSEHOLD MEMBER)

COMPLETE DATA BELOW IF KNOWN COMPLETE DATA BELOW IF KNOWN

DESCRIPTION OF PERSON (No. 3) SUBJECT TO THIS ORDER DESCRIPTION OF PERSON (No. 4) SUBJECT TO THIS ORDER

NAME: 6 NAME: 6
RACE SEX BORN HT. WGT. EYES HAIR RACE SEX BORN HT. WGT. EYES HAIR
MO. DAY YR. FT. IN. MO. DAY YR. FT. IN.

SSN SSN

Check if applicable:
[ ] Relationship of person No. 3 to child’s parent: [ ] child’s other parent [ ] spouse/former spouse [ ] cohabit in present or past.
7 [ ] Relationship of person No. 4 to child’s parent: [ ] child’s other parent [ ] spouse/former spouse [ ] cohabit in present or past.
Having ordered on a prior page of this order the attachment and incorporation of this supplemental sheet for additional findings and/or
orders of this court,

THE COURT FURTHER FINDS AND ORDERS THAT:

9
FORM DC-547 (MASTER, PAGE _____ of _____) 07/13
Form DC-549 ORDER OF EMANCIPATION Form DC-549

Data Elements, page one

1. Insert court case number.

2. Insert date and time of hearing at which this order is entered.

3. Insert court name.

4. Insert name of juvenile.

5. Insert date of birth of juvenile.

6. Check the appropriate boxes to indicate who was present at hearing and insert name of
individual.

7. Check box to indicate petitioning party, and insert name of parent or guardian if parent or
guardian is petitioner.

8. If juvenile does not meet the requirements for entry of an order of emancipation, check
this box.

9. If juvenile meets the requirements for entry of an order of emancipation, check this box.

10. If Data Element No. 9 is checked, check the appropriate box to indicate how juvenile
meets requirements for entry of order of emancipation.

11. Insert name of juvenile.

12. Date of signing of order.

13. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

OCTOBER 2009
Pursuant to § 16.1-334 of the Code of Virginia, 1950, as amended, an order that a minor is emancipated
shall have the following effects:

1. The minor may consent to medical, dental, or psychiatric care, without parental consent,
knowledge, or liability;

2. The minor may enter into a binding contract or execute a will;

3. The minor may sue and be sued in his own name;

4. The minor shall be entitled to his own earnings and shall be free of control by his parents or
guardian;

5. The minor may establish his own residence;

6. The minor may buy and sell real property;

7. The minor may not thereafter be the subject of a petition under this chapter as abused, neglected,
abandoned, in need of services, in need of supervision, or in violation of a juvenile curfew
ordinance enacted by a local governing body;

8. The minor may enroll in any school or college, without parental consent;

9. The minor may secure a driver's license under § 46.2-334 or § 46.2-335 without parental consent;

10. The parents of the minor shall no longer be the guardians of the minor;

11. The parents of a minor shall be relieved of any obligations respecting his school attendance under
Article 1 (§ 22.1-254 et seq.) of Chapter 14 of Title 22.1;

12. The parents shall be relieved of all obligation to support the minor;

13. The minor shall be emancipated for the purposes of parental liability for his acts;

14. The minor may execute releases in his own name;

15. The minor may not have a guardian ad litem appointed for him pursuant to any statute solely
because he is under age eighteen; and

16. The minor may marry without parental, judicial, or other consent.

FORM DC-549 (MASTER, PAGE TWO OF TWO) 10/09

Form DC-550 PETITION REQUESTING AUTHORIZATION FOR Form DC-550
MEDICAL TREATMENT

Using This Form

1. Copies

a. Original - to court.

b. First copy - to petitioning physician (if any).

c. Second copy - to petitioning hospital (if any).

d. Third copy - to person having custody of the juvenile.

e. Additional copies as determined by local practice.

2. Prepared by petitioners.

3. Attachments

a. DC-551, ORDER AUTHORIZING MEDICAL TREATMENT OF JUVENILE - if granted by judge.

4. Preparation Details

a. This petition should be prepared in all cases as a record of the case.

b. In emergency situations where time is a very critical factor, preparation of the petition
may be used to reduce the request to writing after the emergency treatment is completed
if the judge accepts the oral request.

c. The petitioners may be either a hospital or physician or both. Leave blank Data Elements
Nos. 23 through 26 or Data Element No. 27on front of form if inapplicable.

d. The physician who will perform the additional diagnostic testing or treatment does not
have to be a petitioner. In such cases, the petitioning hospital or physician should list the
examining or treating physician in Data Element No. 30.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 1999
PETITION REQUESTING AUTHORIZATION FOR MEDICAL TREATMENT OF JUVENILE
VA. CODE ANN. §§ 16.1-241, 16.1-262, 54.1-2969
COMMONWEALTH OF VIRGINIA Rules 8:3, 8:22 1
Case File .........................................................

In re a Child under eighteen years of age

1. CHILD’S NAME 2. SOCIAL SECURITY NO. 3. DATE OF BIRTH 4. AGE: 5. CHILD EVER MARRIED? SEX
[ ] YES [ ] NO M. F.
3 4 5 6 7 8
6. CHILD’S ADDRESS TELEPHONE NUMBER
9 10
7. FATHER’S NAME 8. FATHER’S ADDRESS TELEPHONE NUMBER

11 12 13
8. MOTHER’S NAME 10. MOTHER’S ADDRESS TELEPHONE NUMBER
14 15 16
11. GUARDIAN/LEGAL CUSTODIAN OR PERSON IN LOCO PARENTIS 12. ADDRESS TELEPHONE NUMBER
17 18 19
13. NAME OF NEAREST RELATIVE IF PARENTS OR GUARDIAN CANNOT BE FOUND 14. ADDRESS TELEPHONE NUMBER

20 21 22

23
................................................................................. , 24
by .......................................................................................... , its 25
............................................................................ ,
NAME OF HOSPITAL OR MEDICAL FACILITY NAME OF AGENT FOR HOSPITAL OR MEDICAL FACILITY TITLE

27
...................................................................................................................................................................................................................... M.D. are the petitioners
NAME AND ADDRESS OF PHYSICIAN

represents to the Court, under oath, the following:

1. The above-named physician is familiar with the present physical condition of the juvenile and the circumstances
surrounding the juvenile, and the physician has examined the juvenile and found the juvenile demonstrating the
following symptoms:
28
....................................................................................................................................................................................................................................................................

2. The physician has made the following diagnosis regarding the juvenile:
29
....................................................................................................................................................................................................................................................................

3. Your petitioners, respectively, recommend and are willing to provide the following necessary medical, surgical and
nursing care if judicial consent is given as requested:
further diagnostic testing, namely:
30
....................................................................................................................................................................................................................................................................

PETITION REQUESTING AUTHORIZATION FOR MEDICAL TREATMENT OF JUVENILE

FORM DC-550 7/92 Page 1 of 2
Form DC-550 PETITION REQUESTING AUTHORIZATION FOR Form DC-550
MEDICAL TREATMENT

Data Elements - Page One

1. Court case number. 18. Address of guardian, legal guardian or

person standing in loco parentis to
2. Name of court. child.

3. Name of child. 19. Telephone number of legal guardian or

person standing in loco parentis to
4. Social security number of child. child.

5. Date of birth of child. 20. Name of nearest relative, if parents or

guardian cannot be found.
6. Age of child.
21. Address of nearest relative.
7. Indicate if child is or has been married.
22. Telephone number of nearest relative.
8. Indicate whether child is male or
female. 23. Name of hospital or medical facility.

9. Address of child. 24. Name of agent from hospital or medical

facility.
10. Telephone number of child.
25. Title of agent.
11. Name of father of child.
26. Address of hospital or medical facility.
12. Address of father.
27. Name and address of physician.
13. Telephone number of father.
28. Describe symptoms.
14. Name of mother of child.
29. Describe diagnosis.
15. Address of mother.
30. Describe further diagnostic testing or
16. Telephone number of mother. treatment.

17. Name of guardian, legal guardian or

person standing in loco parentis to
child.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 1999
treatment namely:
1
.............................................................................................................................................................................................................................................................................

4. The petitioners further represent that the juvenile is within the city or county named above and is subject to the
jurisdiction of this Court. Judicial consent for the above emergency surgical and medical treatment is necessary
because the consent of the juvenile’s parent, guardian, legal custodian or other person standing in loco parentis is
unobtainable in that:

such person is not a resident of this State.

such person’s whereabouts are unknown.
2
such person cannot be consulted with promptness reasonable under the circumstances.
such person fails to give such consent or provide such treatment when requested by the Judge to do so.

Your petitioners request that the Court grant consent to medical, surgical and nursing care and treatment as
described in the petition. The Petitioners further request that the Court order that the parent or other person responsible
for the care and support of the juvenile be responsible to pay the expenses thereof.

3
........................................................................ 4
..........................................................................................................................
DATE NAME OF HOSPITAL OR MEDICAL FACILITY

By: 5
_______________________________________________________
SIGNATURE OF AUTHORIZED AGENT OF HOSPITAL OR MEDICAL FACILITY

Sworn/affirmed and signed before me on 6

........................................................................................................................
DATE

7
........................................................................ ___________________________________________ 8
DATE SIGNATURE

9
................................................................................................... 10
______________________________________________
NAME OF PHYSICIAN PHYSICIAN’S SIGNATURE

Sworn/affirmed and signed before me on 11

........................................................................................................................
DATE

12
........................................................................ 13
___________________________________________
DATE SIGNATURE

NOTICE: Rule 8.22 requires that

1. Any request for judicial consent for emergency medical, surgical or nursing care MUST be filed in
the clerk’s office of the juvenile and domestic relations district court within 5 calendar days from the
date of granting such consent.

2. If the request was made orally, it must be reduced to writing and filed as described above.

FORM DC-550 (MASTER, PAGE TWO OF TWO) 12/99

Form DC-550 PETITION REQUESTING AUTHORIZATION FOR Form DC-550
MEDICAL TREATMENT

Data Elements - Page Two

1. Describe further diagnostic testing or treatment.

2. Check appropriate box to indicate why the otherwise necessary consent cannot be obtained.

3. Date on which agent of hospital signs request.

4. Name of hospital.

5. Signature of agent.

6. Date of acknowledgment.

7. Date acknowledgment signed.

8. Signature of person acknowledging.

9. Name of petitioning physician.

10. Signature of petitioning physician.

11. Date of acknowledgment.

12. Date acknowledgment signed.

13. Signature of person acknowledging.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 1999
Form DC-551 ORDER AUTHORIZING MEDICAL Form DC-551
TREATMENT OF JUVENILES

Using This Form

1. Copies

a. Original – to court.

b. First copy – to authorized physician or hospital. If more than one authorized

person or hospital, prepare a copy for each one of them.

c. Second copy – to petitioner if other than authorized physician or hospital. If more

than one petitioner, prepare a copy for each petitioner.

d. Third copy – to person ordered to pay for treatment (if applicable).

e. Fourth copy – to others designated in order to receive copy of order.

2. Prepared by clerk, signed by judge.

3. Attachments

4. Preparation details

a. This order should be used when a person who can legally consent to the treatment
of the juvenile is not available. If the parents or other person who can give
consent withhold consent, use form DC-552, ORDER AUTHORIZING MEDICAL
TREATMENT OF JUVENILE (CONSENT WITHHELD).

b. This order as printed does not permit delegation of authorization from the person
or hospitals named in the order to others. If such delegation is felt to be
necessary, it should be added in Data Element No. 15 (front).

c. The petitioners may be either a hospital or physician or both. Leave blank Data
Element No. 4 or Data Elements Nos. 5 through 7 if inappropriate.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 1997
ORDER AUTHORIZING MEDICAL TREATMENT OF JUVENILE Case No. 1
..............................................................
COMMONWEALTH OF VIRGINIA VA. CODE ANN. §§ 16.1-241, 54.1-2969

Commonwealth, in re: 3
................................................................................................................................................................................................................................

In re:
...............................................................................................................................................................................................................................................................................
Dr. ................................................................................................................ and ............................................................................................................................................
4
NAME OF PHYSICIAN 5
NAME OF HOSPITAL OR MEDICAL FACILITY

by .................................................................................................................. , its ...............................................................................................................................................

6
NAME OF AGENT FOR HOSPITAL OR MEDICAL FACILITY 7
TITLE

have filed a written petition seeking the Court’s consent to medical and surgical treatment of the above-named juvenile.
8 9
It appearing to the Court that the juvenile is under eighteen years of age, is unmarried, and has never been married, the
juvenile is in immediate need of medical and/or surgical care and that the consent of the parent, guardian or other person standing in
loco parentis is unobtainable with promptness reasonable under the circumstances and necessary for the well-being of the juvenile;
and that his welfare demands an immediate adjudication as to the disposition and control of the juvenile for the purpose of such care, it
is hereby ORDERED that the necessary consent and authorization be given to [ ] the above named physician [ ] the above named
hospital or medical facility to administer the following necessary medical, surgical and nursing care:

10[ ] oral authorization, by telephone, for such care and treatment having been heretofore given by this court on
11
..................................................................................................................... , because of the emergency nature of the juvenile’s condition;
DATE AND TIME

12 [ ] it is further ORDERED that the parent, guardian, or other person standing in loco parentis shall be responsible to pay the
expenses for such necessary medical and surgical treatment for the juvenile.

13 [ ] it is further ORDERED that the Clerk of this Court forward a copy of this Order to the following person(s):
...............................................................................................................................................................................................................................................................................

14
.............................................................................................................................. 15
__________________________________________________
DATE JUDGE

FORM DC-551 7/92 ORDER AUTHORIZING MEDICAL TREATMENT OF JUVENILE Case No. .................................................
Form DC-551 ORDER AUTHORIZING MEDICAL Form DC-551
TREATMENT OF JUVENILES

Data Elements

1. Court case number. If form is clipped to file at top of page, put case number at bottom of
page. Otherwise, put file number at top of page.

2. Court name.

3. Case name (name of juvenile).

4. Physician who petitioned for order, if applicable.

5. Hospital which petitioned for order, if applicable.

6. Name of agent of hospital, if applicable.

7. Title of agent of hospital, if applicable.

8. Check this box if authorization granted to physician name in Data Element No. 4.

9. Check this box if authorization granted to hospital named in Data Element No. 5.

10. Check if oral authorization used.

11. If Data Element No. 10 is checked, insert date and time that oral authorization was given.

12. Check if applicable.

13. Check if applicable and insert names of additional persons who shall receive this order.
Additional space is provided for the judge to add additional provisions in the order.

14. Date of entry of order.

15. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 1997
Form DC-552 FOSTER CARE PLAN TRANSMITTAL Form DC-552

Using This Form

1. Copies

a. For internal use only in the clerk's office.

b. Do not photocopy this form, which is not sent to parties, attorneys, or other
interested persons.

2. Prepared and filed by the local departments of social services, public agency designed by
the community policy and management team, or child welfare agency as the cover sheet
for all foster care plans sent to the court to provide case information such as names and
addresses of parties and interested persons entitled to notice of foster care proceedings.

3. Attachments

a. Initial Foster Care Plan filed pursuant to Va. Code § 16.1-281, as appropriate.

b. DC-554, PETITION FOR FOSTER CARE REVIEW HEARING, as appropriate.

c. DC-556, PETITION FOR PERMANENCY PLANNING HEARING, as appropriate.

4. Preparation details

a. The address for the child should be the child's actual address, not the custodial or
placement agency's address.

b. If the parent is incarcerated, the agency should provide the name and street
address of the penal institution.

c. If the parent's residual parental rights have been terminated or if the parent is
deceased, the agency should indicate this information on the line for that parent's
street address.

d. A parent whose residual parental rights to the child have been terminated should
not be sent a copy of the petition or foster care plan.

e. It has been suggested that the information on the FOSTER CARE PLAN
TRANSMITTAL is not sent to the parties to avoid unauthorized contact or the
commission of violent acts by a parent from whose custody the child was
removed against the other parent, foster parent, or child. However, access to the
document in the court file is allowed as provided by law.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
FOSTER CARE PLAN TRANSMITTAL 1
Court Case No. .........................................................................
Commonwealth of Virginia
Va. Code §§ 16.1-281, 16.1-282, 16.1-282.1, 16.1-282.2 2
Agency Case No. .....................................................................
3
.........................................................................................................
SCHEDULED HEARING DATE AND TIME

USING THIS FORM

• This form is to be used as the cover sheet for all foster care plans sent to court.
• For internal use only in the Clerk’s Office.
• Do not photocopy, share information from, or mail out this form.

4
To the ................................................................................................................................ Juvenile and Domestic Relations District Court
CITY OR COUNTY

5 6 7
In re: .............................................................................................................................. ............................................................. [ ] Age 12 or older
NAME OF CHILD DATE OF BIRTH

The 9
............................................................................................................................................................................................................ hereby submits:
PUBLIC OR PRIVATE CHILD-PLACING AGENCY

[ ] Initial foster care plan (§ 16.1-281) [ ] Petition for initial permanency planning hearing (§ 16.1-282.1)
10 [ ] Petition for 4-month foster care review hearing (§ 16.1-282) [ ] Petition for second permanency planning hearing (§ 16.1-282.1)
[ ] Petition for annual foster care review hearing (§ 16.1-282.2) [ ] Petition for 6-month permanency planning hearing for child with
goal of another planned permanent living arrangement (APPLA)
(§ 16.1-282.1 A2)

INSTRUCTIONS
▪ The following names and address are required by Virginia Code §§ 16.1-281, 16.1-282, 16.1-282.1 and 16.1-282.2.
▪ If the parent is incarcerated, provide the name and street address of the penal institution.
▪ If the parent’s residual parental rights have been terminated, or if the parent is deceased, indicate this information on the line for
that parent’s street address.
Do NOT mail a copy of this plan to a parent whose residual parental rights have been terminated.
If the child is age 12 or older, provide notice and a copy of this plan at the child’s address listed above.

11
.............................................................................................................................. 12
..............................................................................................................................
NAME OF FATHER NAME OF MOTHER

13
.............................................................................................................................. 14
..............................................................................................................................
FOSTER PARENT(S)/FACILITY NAME(S) NAME OF PRIOR CUSTODIAN

15
.............................................................................................................................. 16
..............................................................................................................................
RELATIVE(S)/PERSON DIRECTLY INTERESTED PRE-ADOPTIVE PARENT(S)

FORM DC-552 (MASTER, PAGE ONE OF TWO) 07/14

Form DC-552 FOSTER CARE PLAN TRANSMITTAL Form DC-552

Data Elements, page one

1. Insert court case number.

2. Insert public or private child-placing agency case number.

3. Insert previously scheduled date and time for hearing.

4. Insert court name.

5. Insert name of child who is the subject of the proceeding.

6. Insert date of birth of child.

7. Check box if child is age 12 or older.

8. Insert address of child. See Using This Form, 4a.

9. Insert name of local social services or other child-placing agency.

10. Check appropriate box for document attached.

11. Insert name and address of the child's father. See Using This Form, 4b. and c.

12. Insert name and address of the child's mother. See Using This Form, 4b. and c.

13. Insert name and address of foster parents or facility where child is placed.

14. Insert name and address of the child's prior custodian, if applicable.

15. Insert name and address of an interested relative or other person directly interested in the
matter, if applicable.

16. Insert name and address of pre-adoptive parents, if applicable.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
1
Court Case No. .........................................................................
2
Agency Case No. .....................................................................

3
Attorney for father (name only): .................................................................................................................................................................................................

Attorney for mother (name only): 4

..............................................................................................................................................................................................

5
Guardian ad litem for child (name only): ...............................................................................................................................................................................

Other attorneys (names only of other attorneys with person(s) represented): 6

....................................................................................................

7
Other: .........................................................................................................................................................................................................................................................

8
.................................................... 9
_______________________________________________ 10
...............................................................................
DATE PREPARED SIGNATURE NAME OF CASE WORKER

11
...............................................................................
TELEPHONE NUMBER

Notice sent:

12
.................................................... 13
....................................................
CLERK’S INITIALS DATE

FORM DC-552 (MASTER, PAGE TWO OF TWO) 07/02

Form DC-552 FOSTER CARE PLAN TRANSMITTAL Form DC-552

Data Elements, page two

1. Insert court case number.

2. Insert public or private child-placing agency case number.

3. Insert name of attorney for the child's father.

4. Insert name of attorney for the child's mother.

5. Insert name of guardian ad litem for the child.

6. Insert names of other attorneys involved in the matter and the names of the persons
whom the attorney represents.

7. Insert any other information deemed pertinent.

8. Insert date this form is prepared.

9. Signature of person preparing this form.

10. Insert name of Department of Social Services caseworker.

11. Insert telephone number of caseworker.

12. Clerk's initials to indicate that the appropriate notices have been sent. This line and Data
Element No. 13 are for the clerk's convenience and are not mandatory.

13. Insert date when notices were sent.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
Form DC-553 DISPOSITIONAL ORDER FOR UNDERLYING PETITION; Form DC-553
FOSTER CARE PLAN

Using This Form

1. Copies

a. Original – to court.

b. Copy – to the person or agency with custody of the child or placement

responsibility for the child.

c. Copy – to the attorney for the person or agency with custody of the child or
placement responsibility for the child.

d. Copy – to the child, if he or she is twelve (12) years of age or older.

e. Copy – to the guardian ad litem for the child.

f. Copy – to each parent, unless parental rights have been terminated.

g. Copy – to the attorney(s) for the child’s parents.

h. Copy – to the person standing in loco parentis to the child at the time the agency
obtained custody or placed the child, if any.

i. Copy – to the attorney for the person standing in loco parentis to the child at the
time the agency obtained custody or placed the child.

j. Copy – to any person as appears to the court to have a proper interest in the foster
care plan. It is suggested that a child age twelve (12) years or older is a person
who has a proper interest in the foster care plan.

2. Preparation of the order

a. Page 1 and, if applicable, Page D, prepared by clerk.

b. Pages A, B or C, 2 and 3, if applicable – prepared by judge.

c. Signed by judge on Page A, B or C and 3, as appropriate.

d. Alternatively, Pages 1 and, if applicable, 2, 3 and A, B, C or D prepared by clerk;

Page A, B or C and 3, as appropriate, signed by judge.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
Form DC-553 DISPOSITIONAL ORDER FOR UNDERLYING PETITION; Form DC-553
FOSTER CARE PLAN

Using This Form, continued

3. Attachments

a. Form DC-508, ACKNOWLEDGEMENT OF NEXT HEARING DATE.

b. Form DC-559, SUPPLEMENT TO ORDER TRANSFERRING CUSTODY, if used.

c. If the judge makes any revision in any part of the foster care plan, a copy of the
changes shall be sent by the court to all persons who received a copy of the
original or that part of the plan. Those persons include those who receive a copy
of the DC-553, DISPOSITIONAL ORDER FOR UNDERLYING PETITION, FOSTER CARE
PLAN. In addition, a copy of the changes to the plan, excluding the section of the
plan describing the reasons why the child cannot be returned home and the
alternative chosen, shall be sent by the court to the foster parents. A copy of the
changes to the foster care plan shall not be sent to a parent whose parental rights
to the child have been terminated.

4. Preparation details

a. Follow instructions on page 1, “Using This Form.”

b. At the conclusion of the foster care plan hearing, set a date within 4 months of
this hearing for the foster care review hearing or, as appropriate, within 12 months
for an annual foster care review hearing.

c. Set a date 30 days before the next scheduled hearing by which the agency must
file form DC-554, PETITION FOR FOSTER CARE REVIEW HEARING.

d. These dates and the time for the next hearing should be entered at number 6 on
page 3.

e. The Court Improvement Program suggests entry of the order in the courtroom at
the conclusion of the foster care hearing, and copies of forms DC-553, FOSTER
CARE PLAN DISPOSITIONAL ORDER, and DC-508, ACKNOWLEDGMENT OF NOTICE
OF NEXT HEARING DATE, provided before leaving the court building to all persons
who received a copy of the foster care plan.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
DISPOSITIONAL ORDER UNDERLYING PETITION Court Case No. . . . . . . . .1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FOR UNDERLYING PETITION, FOSTER CARE PLAN Court Case No. . . . . . . . . . . . .2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FOSTER CARE PLAN
Commonwealth of Virginia Agency Case No. . . . . . . . . . . . . . .3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Va. Code §§ 16.1-277.01, 16.1-277.02, 16.1-278.2, 16.1-278.3,
16.1-281, 20-124.5, 63.2-912 4
............................................................................
DATE OF HEARING

[ ] Circuit Court
5
...............................................................................................................[
5 ] Juvenile and Domestic Relations District Court
USING THIS FORM:
• Use this form to dispose of the underlying petition in certain case types and foster care plans filed pursuant to Virginia Code
§ 16.1-281.
• Indicate case type(s) of this child’s case by checking applicable box(es): [ ] Abuse, Neglect, or At Risk of Abuse or Neglect
[ ] Approval of Entrustment Agreement [ ] Relief of Custody [ ] Foster Care Plan.
• Complete page 1, which documents general information about the child’s case.
• The sections outlined individually on three separate pages labeled Page A, Page B and Page C relate to the underlying petition.
Complete only one of these pages per case, as appropriate.
• Complete pages 2 and 3 if a hearing is held to review a foster care plan filed pursuant to Virginia Code § 16.1-281.
• Date and signature lines for entry of the order by the judge should be completed on Page A, B or C, if used to dispose of an
underlying petition, and on page 3 to dispose of a foster care plan, as appropriate.
• The last page of the order, Page D, is used to serve the order, if necessary.

In re: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
.................................................. 7
..............................................................................
NAME OF CHILD DATE OF BIRTH

8
...................................................................... [ ] Putative 9
..............................................................................
NAME OF FATHER NAME OF MOTHER

Present: [ ] Mother . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Mother’s attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

[ ] Father . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Father’s attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10 [ ] Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Guardian ad litem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
[ ] Agency Representative. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Agency Attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
[ ] Foster Parent(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] CASA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
[ ]
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ]
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
A hearing has been held to dispose of the underlying petition filed pursuant to Virginia Code § 16.1-241 and, if applicable, to review
and approve the foster care plan filed on . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . pursuant to Virginia Code § 16.1-281.
DATE

THE COURT FINDS THAT THE CHILD IS WITHIN THE JURISDICTION OF THIS COURT AND, BASED UPON A
PREPONDERANCE OF THE EVIDENCE UNLESS OTHERWISE INDICATED, FINDS AS FOLLOWS:
1. Notice of this hearing was provided to the parents as follows:
[ ] mother [ ] father appeared this date and expressly waived objections to service or accepted service without objection.
[ ] mother [ ] father previously signed form DC-508, ACKNOWLEDGEMENT OF NOTICE OF NEXT HEARING DATE.
12 [ ] mother [ ] father served by personal service for this hearing.
[ ] mother [ ] father served by substituted service for this hearing.
[ ] mother [ ] father served by order of publication.
[ ] mother [ ] father is without the Commonwealth and was served by certified mail, return receipt requested.
OR
[ ] the identity of the [ ] mother [ ] father is not reasonably ascertainable.
OR
[ ] reasonable efforts have been made to locate the [ ] mother [ ] father, who cannot be found.
2. Notice of this hearing and a copy of the foster care plan filed pursuant to Virginia Code § 16.1-281 was sent by the court to the:
[ ] child, if 12 or older [ ] guardian ad litem for child
[ ] mother [ ] attorney for mother
13 [ ] father [ ] attorney for father
[ ] person standing in loco parentis [ ] attorney for person standing in loco parentis
[ ] foster parent(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FORM DC-553 (MASTER, PAGE ONE) 07/14
Form DC-553 DISPOSITIONAL ORDER FOR UNDERLYING PETITION; Form DC-553
FOSTER CARE PLAN

Data Elements, page one

1. Insert the court case number of the underlying petition, if applicable.

2. Insert the court case number of foster care case, if applicable.

3. Insert public or private child-placing agency case number.

4. Insert date of hearing at which this order is entered.

5. Insert name of court. Check box for appropriate court.

6. Insert name of child who is subject of case.

7. Insert date of birth of child.

8. Insert name of father. Check box if paternity has not been established.

9. Insert name of mother.

10. Check boxes to indicate the persons present at the hearing and insert the names of those
present.

11. Insert date hearing was held to dispose, as applicable, of underlying petition and foster
care plan.

12. Check the appropriate box for the notice received by or reason why notice was not
provided to the child’s mother and father.

13. Check appropriate boxes to indicate who was sent a copy of the foster care plan and
notice of the hearing.

DISTRICT COURT MANUAL FORMS VOLUME

3 [ ] The court adjudicated on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . that the child is an
DATE
abused or neglected child, or is at risk of being abused or neglected by a parent or custodian who has been adjudicated as
having abused or neglected another child in the care of the parent or custodian.
AND
4 [ ] Upon disposition of the petition, THE COURT ORDERS:
5 1. [ ] Custody of the child is transferred to
5
............................................................................................................................................................
PUBLIC OR PRIVATE CHILD-PLACING AGENCY OR INDIVIDUAL/ADDRESS
Each non-agency party intending a change of address shall give 30 days advance written notice of such change of
address to the court and other party, pursuant to Virginia Code § 20-124.5. This notice shall contain the child’s full
name, the case number of this case, the party’s new telephone number and new street address and, if different, the
party’s new mailing address. The notice shall be mailed by first-class or delivered to this court and to the other party.

6 2. [ ] As legal custody of the child is transferred for the first time in this case to a public or private child-placing agency, a
hearing shall be held for the purpose of reviewing and approving the foster care plan on
6
................................................................................ at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6. . . . . . . . . . . . . . . . . . . . . . . . . . . ,
DATE TIME
and the agency having placement responsibility for the child shall file a foster care plan in accordance with Virginia
Code § 16.1-281 by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
....................................................................
DATE

7 3. [ ] As legal custody of the child is transferred to a relative or other interested individual, district court form DC-559,
SUPPLEMENT TO ORDER TRANSFERRING CUSTODY, is attached and incorporated in this order.
8 4. [ ] The court has reviewed the preliminary protective order entered in this case on . . . . . . . . . . . . . . . . . . . . . . . . . . .8. . . . . . . . . . . . . . . . . . . .
DATE

and [ ] the order is dissolved or [ ] a final CHILD PROTECTIVE ORDER – ABUSE AND NEGLECT, district court form
DC-532, is attached and incorporated in this order.
9 [ ] As this order transfers custody of the child, THE COURT FURTHER FINDS:
1. That there is no less drastic alternative than transfer of legal custody as provided in this order.
10 2. [ ] As custody of the child is transferred to a local board of social services, that:
a. [ ] Continued placement in the home would be contrary to the welfare of the child, based upon:
[ ] the facts contained in the following document(s), which is (are) incorporated by reference:
11 [ ] sustained petition. [ ] entrustment agreement.
[ ] affidavit. [ ] department of social services report.
[ ] the following facts: ...............................................................................................................

13 [ ] Other: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..............................................................................................................................................................................

14
............................................................
15
_______________________________________________________
JUDGE
DATE

FORM DC-553 (MASTER, PAGE A) 07/14

Form DC-553 DISPOSITIONAL ORDER FOR UNDERLYING PETITION; Form DC-553
FOSTER CARE PLAN

Data Elements, page A

1. Insert the court case number of the underlying petition, if applicable.

2. Insert the court case number of the foster care case, if applicable.

3. Check box to indicate the case involves abuse, neglect or at risk of abuse or neglect, and
insert the date of adjudication of the underlying petition.

4. Check box to indicate disposition of the petition.

5. Check box if legal custody of the child is transferred to dispose of the underlying petition,
and insert name of public or private child-placing agency or individual and address of
legal custodian.

6. Check box, if applicable, insert the date and time for a hearing to review the foster care
plan and the date by which the public or private child-placing agency must submit the
foster care plan to the court.

7. Check box, if applicable.

8. Check applicable boxes and insert date the preliminary protective order was entered, as
appropriate.

9. Check box, if applicable.

DISTRICT COURT MANUAL FORMS VOLUME

3 [ ] Based upon evidence presented upon adjudication of the petition filed pursuant to Virginia Code § 16.1-241 seeking
approval of the entrustment agreement executed on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
.............................................. ,
DATE
THE COURT FINDS:
4[ ] by a preponderance of the evidence, the temporary entrustment agreement is in the best interest of the child.
[ ] by clear and convincing evidence, the entrustment agreement which provides for the termination of parental rights is
in the best interest of the child.
5 [ ] A separate ORDER FOR VOLUNTARY TERMINATION OF PARENTAL RIGHTS is attached and incorporated herein.

6 [ ] Upon disposition of the petition, THE COURT ORDERS:

7 1. [ ] Entrustment agreement is approved.
8 2. [ ] Custody of the child is transferred to
8
............................................................................................................................................................
PUBLIC OR PRIVATE CHILD-PLACING AGENCY OR INDIVIDUAL/ADDRESS
Each non-agency party intending a change of address shall give 30 days advance written notice of such change of
address to the court and other party, pursuant to Virginia Code § 20-124.5. This notice shall contain the child’s full
name, the case number of this case, the party’s new telephone number and new street address and, if different, the
party’s new mailing address. The notice shall be mailed by first-class or delivered to this court and to the other party.
9 3. [ ] As legal custody of the child is transferred to a relative or other interested individual, district court form DC-559,
SUPPLEMENT TO ORDER TRANSFERRING CUSTODY, is attached and incorporated in this order.

10 [ ] As this order transfers custody of the child, THE COURT FURTHER FINDS:
1. That there is no less drastic alternative than transfer of legal custody as provided in this order.
11 2. [ ] As custody of the child is transferred to a local board of social services, that:
a. [ ] Continued placement in the home would be contrary to the welfare of the child, based upon:
[ ] the facts contained in the following document(s), which is (are) incorporated by reference:
12 [ ] sustained petition. [ ] entrustment agreement.
[ ] affidavit. [ ] department of social services report.
[ ] the following facts: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..........................................................................................................................................

..........................................................................................................................................
AND
b. [ ] Reasonable efforts [ ] have been made [ ] have not been made to prevent removal of the child from the
home, based upon:
[ ] the facts contained in the following document(s), which is (are) incorporated by reference:
13 [ ] sustained petition. [ ] entrustment agreement.
[ ] affidavit. [ ] department of social services report.
[ ] the following facts: ...............................................................................................................

..........................................................................................................................................

14 [ ] Other: ....................................................................................................................................................................
14
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................

15
............................................................ 16
_________________________________________________
DATE JUDGE

FORM DC-553 (MASTER, PAGE B) 07/14

Form DC-553 DISPOSITIONAL ORDER FOR UNDERLYING PETITION; Form DC-553
FOSTER CARE PLAN

Data Elements, page B

1. Insert the court case number of the underlying petition, if applicable.

2. Insert the court case number of the foster care case, if applicable.

3. Check box to indicate adjudication of a petition for approval of an entrustment agreement

and insert date the agreement was executed.

4. Check applicable box.

5. Check box, if applicable.

6. Check box to indicate disposition of the petition.

7. Check box, as appropriate.

8. Check box if legal custody of the child is transferred to dispose of the underlying petition,
and insert name of public or private child-placing agency or individual and address of
legal custodian.

9. Check box, if applicable.

10. Check box, if applicable.

11. Check box, if applicable.

12. Check the applicable boxes and specify on the lines facts that substantiate that continued
placement in the home would be contrary to the welfare of the child, as appropriate.

13. Check the applicable boxes and specify on the lines provided facts that substantiate the
Court’s finding on reasonable efforts to prevent removal of the child from home.

14. Check box, if applicable, and insert other findings or orders of the court.

15. Insert date order is signed.

16. Judge’s signature.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
UNDERLYING PETITION Court Case No. . . . . . . . .1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FOSTER CARE PLAN Court Case No. . . . . . . . . . . . . . .2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Relief of custody.
3 [ ] Based upon evidence presented upon adjudication of the petition filed pursuant to Virginia Code § 16.1-241 seeking relief
of custody, THE COURT FINDS:
[ ] by a preponderance of the evidence, there is good cause for the petitioner’s desire to be relieved temporarily of custody.
4 [ ] by clear and convincing evidence, granting the petition for permanent relief of custody is in the best interest of the child.
5 [ ] A separate ORDER FOR VOLUNTARY TERMINATION OF PARENTAL RIGHTS is attached and incorporated in this order.
6 [ ] Upon disposition of the petition, THE COURT ORDERS:
7 1. [ ] Relief of custody is granted.
8 2. [ ] For partial disposition, temporary custody of the child is transferred to
8
............................................................................................................................................................
PUBLIC OR PRIVATE CHILD-PLACING AGENCY OR INDIVIDUAL

9 3. [ ] For final disposition, custody of the child is transferred to

9
............................................................................................................................................................
PUBLIC OR PRIVATE CHILD-PLACING AGENCY OR INDIVIDUAL/ADDRESS
Each non-agency party intending a change of address shall give 30 days advance written notice of such change of
address to the court and other party, pursuant to Virginia Code § 20-124.5. This notice shall contain the child’s full
name, the case number of this case, the party’s new telephone number and new street address and, if different, the
party’s new mailing address. The notice shall be mailed by first-class or delivered to this court and to the other party.
10 4. [ ] A hearing shall be held on . . . . . . . . . . . . . . . . . . . . . 10 10
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at ............................................ :
DATE TIME

[ ] for final disposition of the petition.

11 [ ] for the purpose of reviewing and approving a foster care plan, which shall be filed in accordance with Virginia
Code § 16.1-281 by the public or private child-placing agency having placement responsibility for the child by
11
........................................................................................................................ .
DATE

12 5. [ ] As this order, whether temporary or final, transfers legal custody of the child to a relative or other interested
individual, district court form DC-559, SUPPLEMENT TO ORDER TRANSFERRING CUSTODY, is attached and
incorporated in this order.
6. [ ] The court has reviewed the preliminary protective order entered in this case on ...............................................
DATE
13 and [ ] the order is dissolved or [ ] a final CHILD PROTECTIVE ORDER – ABUSE AND NEGLECT, district court form
DC-532, is attached and incorporated in this order.
14 [ ] As this order transfers custody of the child, even temporarily, THE COURT FURTHER FINDS:
1. That there is no less drastic alternative than transfer of legal custody as provided in this order.
15 2. [ ] As custody of the child is transferred to a local board of social services, that:
a. [ ] Continued placement in the home would be contrary to the welfare of the child, based upon:
[ ] the facts contained in the following document(s), which is (are) incorporated by reference:
16 [ ] sustained petition. [ ] entrustment agreement.
[ ] affidavit. [ ] department of social services report.
[ ] the following facts: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..........................................................................................................................................
AND
b. [ ] Reasonable efforts [ ] have been made [ ] have not been made to prevent removal of the child from the
home, based upon:
[ ] the facts contained in the following document(s), which is (are) incorporated by reference:
17 [ ] sustained petition. [ ] entrustment agreement.
[ ] affidavit. [ ] department of social services report.
[ ] the following facts: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..........................................................................................................................................
18 [ ] Other: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......................................................................................................................................................................

19
................................................ 20
______________________________________________
DATE JUDGE

FORM DC-553 (MASTER, PAGE C) 07/14

Form DC-553 DISPOSITIONAL ORDER FOR UNDERLYING PETITION; Form DC-553
FOSTER CARE PLAN

Data Elements, page C

1. Insert court case number of the underlying petition, if applicable.

2. Insert the court case number of the foster care case, if applicable.
3. Check box to indicate adjudication of a petition for relief of custody.
4. Check applicable box.
5. Check box, if applicable.
6. Check box to indicate disposition of the petition.
7. Check box, as appropriate.
8. Check box if temporary legal custody of the child is transferred to partially dispose of the
underlying petition, and insert name of public or private child-placing agency or
individual and address of legal custodian.
9. Check box if legal custody of the child is transferred to dispose of the underlying petition,
and insert name of public or private child-placing agency or individual and address of
legal custodian.
10. Check box, if applicable, and insert date and time of next hearing.
11. Check applicable box(es) and insert date by which public or private child-placing agency
must submit foster care plan, as appropriate.
12. Check box, if applicable.
13. Check applicable boxes and insert date the preliminary protective order was entered, as
appropriate.
14. Check box, if applicable.
15. Check box, if applicable.
16. Check the applicable boxes and specify on the lines facts that substantiate that continued
placement in the home would be contrary to the welfare of the child, as appropriate.
17. Check the applicable boxes and specify on the lines provided facts that substantiate the
Court’s finding on reasonable efforts to prevent removal of the child from home.
18. Check box, if applicable, and insert other findings or orders of the court.
19. Insert date order is signed.
20. Judge’s signature.

DISTRICT COURT MANUAL FORMS VOLUME

A HEARING HAS BEEN HELD ON THE FOSTER CARE PLAN FILED PURSUANT TO VIRGINIA CODE § 16.1-281, AND:
3 1. The above-named child:
[ ] has been placed through an agreement with the local board of social services where legal custody remains with the parents or
guardian,
OR
[ ] is in the legal custody of the local board of social services or child welfare agency.

Transfer of custody or placement occurred on . . . . . . . . . . . . . . .4

. . . . . . . . . . . . . to . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
.....................................
DATE PUBLIC OR PRIVATE CHILD-PLACING AGENCY
as a result of:
[ ] a court order in child abuse or neglect case.
[ ] a court order in case of a child at risk of abuse or neglect by a parent or custodian who has been adjudicated as having abused
or neglected another child in the care of the parent or custodian.
[ ] an entrustment agreement by parents.
6 [ ] a court order in relief of custody case.
[ ] a court order in [ ] child in need of services case or [ ] child in need of supervision or [ ] status offense case or
[ ] delinquency case.
[ ] a placement agreement with child’s parents or guardian.
[ ] other: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7 2. [ ] a. With reference to the foster care plan with the goal of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FOSTER CARE PLAN GOAL
filed pursuant to Virginia Code § 16.1-281, the plan is:
[ ] approved as submitted and incorporated by reference.
OR
[ ] approved with the following revisions and, as revised, is incorporated by reference . . . . . . . . . . . . . . . . . .9. . . . . . . . . . . . . . . . . . . . . . . . .
............................................................................................................................................................
............................................................................................................................................................
8 The clerk shall send a copy of any revisions to all persons who received that part of the original plan.
OR
[ ] disapproved and a new plan shall be submitted to the court by ....................................................................... 10
DATE
for a hearing on . . . . . . . . . . . . . . . . . . . . . . . . . .10
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . . . . . . . . .10
.............................................
DATE TIME

b. [ ] Reasonable efforts to reunite the child with the parents are not required under Virginia Code § 16.1-281 B, and a
permanency planning hearing shall be held on . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . .11
............ ,
DATE TIME
which is within 30 days of this hearing to review the foster care plan.
[ ] As the effect of an order entered at this hearing is to achieve a permanent goal for the child by terminating residual
parental rights, placing the child in permanent foster care, or if the child has been admitted to the United States as a
refugee or asylee, has attained the age of sixteen years and the plan for the child is independent living, directing the
12 board or agency to provide the necessary services to transition from foster care, reasonable efforts:
[ ] have been made [ ] have not been made to place the child in a timely manner in accordance with the foster
care plan and to complete the steps necessary to finalize the permanent placement of the child.
AND
13 c. The court’s determinations are based upon:
[ ] the facts contained in the foster care plan, which is incorporated by reference [ ] the following facts:
..................................................................................................................................................................
13
..................................................................................................................................................................
..................................................................................................................................................................

FORM DC-553 (MASTER, PAGE TWO) 07/14

Form DC-553 DISPOSITIONAL ORDER FOR UNDERLYING PETITION; Form DC-553
FOSTER CARE PLAN

Data Elements, page two

1. Insert the court case number of the underlying petition, if applicable.

2. Insert the court case number of the foster care plan, if applicable.

3. Check appropriate box to indicate whether legal custody remains with the parents or has
been transferred to a public or private child-placing agency.

4. Insert date on which placement was made or legal custody was transferred.

5. Insert name of the public or private child-placing agency to which custody was
transferred or with which child was placed.

6. Check the box that corresponds with the reason why child’s legal custody was changed or
why child was placed with the public or private child-placing agency.

7. Check box, if applicable, and insert foster care plan goal.

8. Check appropriate box for approval or disapproval of foster care plan.

9. Insert any revisions made to the foster care plan by the court.

10. If foster care plan is disapproved insert date by which the agency shall file a new foster
care plan and the date and time of next hearing.

11. Check box, if applicable, and insert date and time of permanency planning hearing.

12. Check boxes, if applicable.

13. If a reasonable efforts finding is made above, check applicable box(es) and specify facts
that substantiate the Court’s finding, as appropriate.

DISTRICT COURT MANUAL FORMS VOLUME

3. [ ] Custody of the child is transferred to

........................................................................................................................................................................
PUBLIC OR PRIVATE CHILD-PLACING AGENCY OR INDIVIDUAL/ADDRESS
4[ ] If legal custody of the child is transferred to a relative other than the child’s prior family, district court form DC-559,
SUPPLEMENT TO ORDER TRANSFERRING CUSTODY, is attached and incorporated in this order.

5 4. [ ] With reference to visitation with the child, who has been placed in foster care:
a. [ ] The mother has had an ongoing relationship with the child prior to the child being placed in foster care, and it is in
the best interests of the child that the relationship continue.
Visitation between the child and the mother shall be
[ ] reasonable and in the discretion of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PUBLIC OR PRIVATE CHILD-PLACING AGENCY
OR
[ ] as follows: ................................................................................................................................

b. [ ] The father has had an ongoing relationship with the child prior to the child being placed in foster care, and it is in the
best interests of the child that the relationship continue.
Visitation between the child and the father shall be
[ ] reasonable and in the discretion of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PUBLIC OR PRIVATE CHILD-PLACING AGENCY
OR
[ ] as follows: ................................................................................................................................
6 c. [ ] The child has a sibling(s) with whom there has been an ongoing relationship prior to the child being placed in foster
care, and it is in the best interests of the child that the relationship continue.
Visitation between the child and the sibling(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . shall be
NAME OF SIBLING(S)
[ ] reasonable and in the discretion of .................................................................................................
PUBLIC OR PRIVATE CHILD-PLACING AGENCY
OR
[ ] as follows: ................................................................................................................................

d. [ ] The child has a grandparent(s) with whom there has been an ongoing relationship prior to the child being placed in
foster care, and it is in the best interests of the child that the relationship continue.
Visitation between the child and the grandparent(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . shall be
NAME OF GRANDPARENT(S)
[ ] reasonable and in the discretion of .................................................................................................
PUBLIC OR PRIVATE CHILD-PLACING AGENCY
OR
[ ] as follows: ................................................................................................................................

7 5. [ ] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . shall continue to utilize reasonable efforts

PUBLIC OR PRIVATE CHILD-PLACING AGENCY
in making appropriate service referrals to the parent, child and foster parents as applicable to accomplish the goals set forth in
the foster care plan approved herein and orders of the court entered herein. The parents shall continue to utilize their best
efforts to fulfill the requirements of the foster care plan approved herein and orders of the court entered herein.
6. [ ] A foster care review hearing pursuant to Virginia Code § 16.1-282 shall be held on ............................... at . . . . . . . . . . . . . . . . . . . .
DATE TIME
.......................................................................................... shall file a petition for foster care review hearing pursuant
PUBLIC OR PRIVATE CHILD-PLACING AGENCY

to Virginia Code § 16.1-282 by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , which is within 3 months from

8
DATE
the date of this dispositional hearing at which the foster care plan was reviewed pursuant to Virginia Code § 16.1-281.
OR
[ ] An annual foster care review hearing pursuant to Virginia Code § 16.1-282.2 shall be held on ...........................................
DATE
at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , which is within twelve months of the entry of this order.
TIME

........................................................... shall file a petition for foster care review hearing and foster care plan pursuant to
PUBLIC OR PRIVATE CHILD-PLACING AGENCY

Virginia Code § 16.1-282.2 by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DATE

FORM DC-553 (MASTER, PAGE THREE ) 07/14

Form DC-553 DISPOSITIONAL ORDER FOR UNDERLYING PETITION; Form DC-553
FOSTER CARE PLAN

Data Elements, page three

1. Insert the court case number of the underlying petition, if applicable.

2. Insert the court case number of the foster care plan, if applicable.

3. Check box if custody of the child is transferred to dispose of the foster care plan and
insert name of agency or individual and address.

4. Check box, if applicable.

5. Check box if visitation is an issue.

6. Check the applicable boxes and insert appropriate information regarding any visitation
ordered.

7. Check box and insert name of public or private child-placing agency.

8. Check appropriate box, if applicable, and insert date and time of foster care review
hearing, name of public or private child-placing agency and date by which petition and
foster care plan must be filed.

DISTRICT COURT MANUAL FORMS VOLUME

3 7. [ ] Other: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........................................................................................................................................................................
........................................................................................................................................................................
4 8. [ ] This order having been entered in the ............................................................................... Circuit Court, the matter is
CITY OR COUNTY

referred pursuant to Virginia Code § 16.1-297 to the ........................................................................................................... Juvenile and

CITY OR COUNTY
Domestic Relations District Court for future proceedings.
5
.......................................................... _____________________________________________________________ 6
DATE JUDGE

FORM DC-553 (MASTER, PAGE FOUR) 07/14

Form DC-553 DISPOSITIONAL ORDER FOR UNDERLYING PETITION; Form DC-553
FOSTER CARE PLAN

Data Elements, page four

1. Insert the court case number of the underlying petition, if applicable.

2. Insert the court case number of the foster care plan, if applicable.

3. Check box, if applicable, and insert other orders of the court.

4. For use by a circuit court referring the case back to the juvenile and domestic relations
district court.

5. Insert date signed by judge.

6. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

Use these boxes for serving this order if any terms and conditions of prior orders entered in this case are modified above.

RETURNS: Each person was served according to law, as indicated below, unless not found.

3
NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.......................................................... ............................................................. ........................................................
3
ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.......................................................... ............................................................. ........................................................

Tel. Tel. Tel.

4 [ ] PERSONAL SERVICE 3
No. . . . . . . . . . . . . . . . . . .
[ ] PERSONAL SERVICE No. . . . . . . . . . . . . . . . . . . .
[ ] PERSONAL SERVICE No. . . . . . . . . . . . . . . . . . . .

5[ ] NOT FOUND [ ] NOT FOUND [ ] NOT FOUND

6
_____________________________________
SERVING OFFICER
__________________________________________
SERVING OFFICER
__________________________________________
SERVING OFFICER

. . . . .8
........ for _____________________________ 7 . . . . . . . . . . . . . . for _______________________________ ........... for_____________________________

FORM DC-553 (MASTER, PAGE D) 7/02

Form DC-553 DISPOSITIONAL ORDER FOR UNDERLYING PETITION; Form DC-553
FOSTER CARE PLAN

Data Elements, page D

1. Insert the court case number of the underlying petition, if applicable.

2. Insert the court case number of the foster care plan, if applicable.

3. Insert name and address (and telephone number if known) of party to be served (to be
inserted by clerk or judge).

4. Serving officer to check this box if personal service obtained.

5. Serving officer to check this box if person to be served could not be found.

6. Signature of serving officer.

7. Insert name of jurisdiction/agency. Insert name of sheriff if served by deputy sheriff.

8. Insert date of signature.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
Form DC-554 PETITION FOR FOSTER CARE Form DC-554
REVIEW HEARING

Using This Form

1. Copies

a. Original – to court.
b. Copy – sent by the court to the child, if s/he is twelve years of age or older.
c. Copy – sent by the court to the guardian ad litem for the child.
d. Copy – sent by the court to each parent, unless parental rights have been
terminated.
e. Copy – sent by the court to any person standing in loco parentis to the child at the
time the agency obtained custody or placed the child.
f. Copy – sent by the court to the person or agency with custody of the child or
placement responsibility for the child.
g. Copy – sent by the court to the attorney for the person or agency with custody of
the child or placement responsibility for the child.
h. Copy – sent by the court to the foster parent or foster parents or other care
providers of the child, except the section of the foster care plan describing the
reasons why the child cannot be returned home and the alternative chosen.
i. Copy – sent by the court to such other persons as the court may direct, including
but not limited to pre-adoptive parents, if any.
j. Copy – sent by the court to all attorneys of record not listed above.

2. Prepared and filed by the public or private child-placing agency with custody or
placement responsibility for the child.

3. Attachments

a. Foster Care Plan – Review (Agency Form).

b. Adoption Progress Report (Department of Social Services Form), as appropriate.
c. New Foster Care Plan (for change in child’s foster care plan goal).
d. Form DC-510, SUMMONS, if the parent or guardian of the child did not appear at
the initial foster care plan hearing held pursuant to § 16.1-281 and was not noticed
to return for the foster care review hearing.
e. Form DC-512, NOTICE OF HEARING.

4. Preparation details

a. It is suggested that the agency with custody of or placement responsibilities for

the child should provide the court with enough copies of the petition and foster
care plan for service on or notice to the parties.
b. The copy sent to the child should be to his or her own address, not the custodial or
placement agency’s address.
c. A parent whose residual parental rights to the child have been terminated should
not be sent a copy of the petition or foster care plan.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2013
PETITION FOR FOSTER CARE REVIEW HEARING Court Case No. . . . . . . . .1
....................................
Commonwealth of Virginia Va. Code §§ 16.1-282, 16.1-282.1 A2, 16.1-282.2
Agency Case No. . . . . . . . .2
.................................

3
.............................................................................................................. Juvenile and Domestic Relations District Court

In re: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
...........................................................................................
NAME OF CHILD

[ ] Male
5
.................................................................
6 [ ] Female 7
.............................................................................
AGE (YEARS/MONTHS) DATE OF BIRTH

[ ] has been placed through an agreement with the local board of social services OR
8[ ] is in legal custody of [ ] the local board of social services or [ ] a child welfare agency.

Transfer of custody or placement occurred on . . . . . . . . . . . .9

. . . . . . . . . . . . . . . . . . to . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
...............................................
DATE PUBLIC OR PRIVATE CHILD-PLACING AGENCY

I, the undersigned Petitioner, state under oath to the best of my knowledge and belief that the following are true:
1. [ ] The above-named child is the subject of a foster care review hearing pursuant to Virginia Code § 16.1-282 because a
foster care plan was filed in this court pursuant to Virginia Code § 16.1-281 and, since the dispositional hearing
held on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at which the foster care plan was reviewed, the child has been:
DATE

[ ] placed through an agreement with the board of social services where legal custody remains with the parents or
guardian and such agreement has not been dissolved by court order; or
[ ] in the legal custody of the board or child welfare agency and the child has not had a petition to terminate parental
rights granted, filed or ordered to be filed on his or her behalf; has not been placed in permanent foster care; or is age
16 or over and the plan for the child is not independent living.
OR
[ ] The above-named child is the subject of a semi-annual foster care review hearing pursuant to Virginia Code § 16.1-282.1
11
A2 because a hearing was held on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . and placement of the child in
DATE
another planned permanent living arrangement was approved as the plan for the child for a maximum of 6 months.
OR
[ ] The above-named child is the subject of an annual foster care review hearing pursuant to Virginia Code § 16.1-282.2
because a hearing was held on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . and the child:
DATE

[ ] has had a petition to terminate parental rights granted, filed or ordered to be filed on his or her behalf; or
[ ] is placed in permanent foster care; or
[ ] has been admitted to the United States as a refugee or asylee and is age 16 or over and the plan for the child is
independent living.

2. The following documents are attached and incorporated herein:

[ ] foster care plan with the goal of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (review) [ ] and Adoption Progress Report or
12 FOSTER CARE PLAN GOAL

[ ] new foster care plan with the goal of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (change in goal).

FOSTER CARE PLAN GOAL

Wherefore, Petitioner requests that the Court grant the following relief and such other relief as the child’s best interest
requires:

1. Docket the case for review to be held within 30 days if a hearing was not previously scheduled pursuant to Virginia Code
§ 16.1-281 E, § 16.1-282 E, § 16.1-282.1 A2 or § 16.1-282.2 A.

2. Provide notice of hearing and a copy of the petition, pursuant to Virginia Code § 16.1-282 C, to the following at addresses
provided on the attached transmittal form:
• Child, if he/she is twelve years of age or older;
• Guardian ad litem for the child;
• Child’s parents and any person standing in loco parentis at the time agency assumed custody;
• Foster parents or other care providers of child;
• Petitioning board of social services or other child welfare agency; and
• Such other persons as the Court may direct, including but not limited to pre-adoptive parents, if any.

FORM DC-554 (MASTER, PAGE ONE OF TWO) 07/13

Form DC-554 PETITION FOR FOSTER CARE Form DC-554
REVIEW HEARING

Data Elements, page one

1. Insert court case number.

2. Insert the public or private child-placing agency case number.

3. Insert name of court.

4. Insert name of child who is the subject of the case.

5. Insert age of child.

6. Check appropriate box for gender of child.

7. Insert date of birth of child.

8. Check appropriate box.

9. Insert date transfer of custody or placement occurred.

10. Insert name of the public or private child-placing agency to which legal custody was
transferred or with which child was placed.

11. Check applicable box(es) and if appropriate, insert date on which permanency planning
hearing was held.

12. Check box(es) to indicate documents attached, and insert foster care plan goal on the line
provided.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2013
Court Case No. . . . . . . . . . . . . . . .1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Enter a finding that:
[ ] reasonable efforts have been made by the agency to reunite child with his or her parents, guardian or other person standing
in loco parentis; or
[ ] reasonable efforts have not been made by agency to reunite child with his or her parents, guardian or other person standing
in loco parentis; and/or
2 [ ] reasonable efforts to reunite child with parents are not required pursuant to Virginia Code § 16.1-281 B.
[ ] reasonable efforts have been made to place the child in a timely manner in accordance with the foster care plan
and to monitor the child’s status in another planned permanent living arrangement.
[ ] reasonable efforts have been made to place the child in a timely manner in accordance with the foster care plan
and to complete the steps necessary to finalize the permanent placement of the child.

4. Enter an order of disposition consistent with the dispositional alternatives available to the court at the original hearing,
specifically, approving and adopting the attached foster care plan as being in the best interest of the child.

5. [ ] As the child is before the court for a foster care review hearing pursuant to Virginia Code § 16.1-282:
[ ] Schedule a date for a permanency planning hearing to be held pursuant to Virginia Code § 16.1-282.1 within 5 months
of this requested foster care review hearing; or
[ ] Schedule a date for an annual foster care review hearing to be held pursuant to Virginia Code § 16.1-282.2 within 12
months of this requested foster care review hearing for a child who remains in the legal custody of a board or child
welfare agency and: on whose behalf a petition to terminate parental rights has been granted, filed or ordered to be
filed; who is placed in permanent foster care; or who has been admitted to the United States as a refugee or asylee and
is age 16 or over and for whom the plan is independent living.
OR

3 [ ] As the child is before the court for a foster care review hearing pursuant to Virginia Code § 16.1-282.1 A2, schedule a date
in 6 months for review of the child’s placement in another planned permanent living arrangement.
OR
[ ] As the child is before the court for an annual foster care review hearing pursuant to Virginia Code § 16.1-282.2:
[ ] Schedule a date in 6 months for filing the next Adoption Progress Report;
and/or
[ ] Schedule a date for an annual foster care review hearing to be held pursuant to Virginia Code § 16.1-282.2 within 12
months of this requested foster care review hearing for a child who remains in the legal custody of the board or child
welfare agency and: on whose behalf a petition to terminate parental rights has been granted, filed or ordered to be
filed; who is placed in permanent foster care; or who has been admitted to the United States as a refugee or asylee and
is age 16 or over and for whom the plan is independent living.

6. [ ] Other: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4 ....................................................................................................................................................................

....................................................................................................................................................................

5
...................................................................................
PUBLIC OR PRIVATE CHILD-PLACING AGENCY

6
............................................... 7
_________________________________________________
DATE PETITIONER

Subscribed and sworn to before me this . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

.................................
DATE

9
_________________________________________________
[ ] INTAKE OFFICER [ ] CLERK

FOR NOTARY PUBLIC’S USE ONLY:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] City [ ] County of . . . . . . . . . . . . . . . . . . . . . . .11

State of . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 ......................................

Acknowledged, subscribed and sworn to before me this . . . . . . . . . . . . . . day of . . . . . . . . . 12

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , 20 . . . . . . . . . . . . . . . . . .

13
............................................................... ___________________________________________________________ 14
NOTARY REGISTRATION NUMBER NOTARY PUBLIC
14
(My commission expires: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . )

FORM DC-554 (MASTER, PAGE TWO OF TWO) 07/13

Form DC-554 PETITION FOR FOSTER CARE Form DC-554
REVIEW HEARING

Data Elements, page two

1. Insert court case number.

2. Check box(es) to indicate the findings requested by petitioner.

3. Check appropriate box to indicate review(s) requested.

4. Check box and insert any other requests.

5. Insert name of petitioning public or private child-placing agency.

6. Insert date signed by petitioner.

7. Signature of petitioner.

8. Insert date on which signature of petitioner is verified.

9. Signature of officer verifying signature of petitioner. Check box to indicate title.

10. If acknowledgment taken by a notary public (Data Elements Nos. 10 to 14), insert state in
which acknowledgment is taken.

11. Locality in which acknowledgment is taken. Check the applicable box to indicate the
city or county.

12. Insert date of acknowledgment.

13. Insert notary’s registration number.

14. Provide signature of notary public taking acknowledgment and expiration date of
commission

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2013
Form DC-555 FOSTER CARE REVIEW ORDER Form DC-555

Using This Form

1. Copies
a. Original – for the court.
b. Copy – to the child, if s/he is twelve years of age or older.
c. Copy – to the guardian ad litem for the child.
d. Copy – to each parent, unless parental rights have been terminated.
e. Copy – to any person standing in loco parentis to the child at the time the agency
obtained custody or placed the child.
f. Copy – to the person or agency with custody of the child or placement responsibility
for the child.
g. Copy – to the attorney for the person or agency with custody of the child or
placement responsibility for the child.
h. Copy – to the foster parent or foster parents or other care providers of the child.
i. Copy – to such other persons as the court may direct, including but not limited to pre-
adoptive parents, if any.
j. Copy – to all attorneys of record not listed above.
2. Preparation of the order
a. Numbers 1-4, prepared by clerk.
b. Numbers 5-10, prepared by judge.
c. Signed by judge.
d. Alternatively, numbers 1-10 prepared by clerk, signed by judge.
3. Attachments
a. Form DC-508, ACKNOWLEDGEMENT OF NEXT HEARING DATE, as appropriate.
b. Form DC-559, SUPPLEMENTAL TO ORDER TRANSFERRING CUSTODY, if used.
c. If the judge makes any revision in any part of the foster care plan, a copy of the
changes shall be sent by the court to all persons who received a copy of the original
or that part of the plan.
4. Preparation details
a. Note that the information required in section number 3 of the DC-555, FOSTER CARE
REVIEW ORDER, on placement or transfer of custody and the reason for the child’s
placement in foster care, may be found on page 2 at section number 1 of the DC-553,
DISPOSITIONAL ORDER FOR UNDERLYING PETITION, FOSTER CARE PLAN. The
information on placement or transfer of custody may also be found at the top of the
DC-554, PETITION FOR FOSTER CARE HEARING.
b. Note that the information required in section number 4 of the DC-555, FOSTER CARE
REVIEW ORDER, may be found at section number 1 of the DC-554, PETITION FOR
FOSTER CARE REVIEW HEARING, filed in this case.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
Form DC-555 FOSTER CARE REVIEW ORDER Form DC-555

c. At the conclusion of the foster care review hearing pursuant to Virginia Code § 16.1-
282, set a date within 5 months of this hearing for the first permanency planning
hearing.
d. At the conclusion of a foster care review hearing pursuant to Virginia Code § 16.1-
282.1 (A2), set a date for the next required foster care review hearing.
e. At the conclusion of an annual foster care review hearing pursuant to Virginia Code
§ 16.1-282.2, set a date for filing the next Adoption Progress Report, if applicable,
and for the next annual foster care review hearing.
f. Set a date 30 days before that next scheduled hearing by which the agency must file
the DC-556, PETITION FOR PERMANENCY PLANNING HEARING, or DC-554, PETITION
FOR FOSTER CARE REVIEW HEARING, as appropriate.

g. These dates and the times for the next hearing should be entered at section number 9
on page 3 or 4.
h. The Court Improvement Program suggests entry of the order in the courtroom at the
conclusion of the foster care review hearing, and copies of the DC-555 and DC-508
provided before leaving the court building to all persons who received a copy of the
PETITION FOR FOSTER CARE REVIEW HEARING.
i. A copy of the DC-508, ACKNOWLEDGEMENT OF NEXT HEARING DATE, should not be
provided to a parent whose parental rights to the child have been terminated.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
FOSTER CARE REVIEW ORDER 1
Case No. ......................................................................................................
Commonwealth of Virginia Va. Code §§ 16.1-282, 16.1-282.1 A2, 16.1-282.2 2
Agency Case No. .....................................................................................
3
.........................................................................................................................
DATE OF HEARING

[ ] Circuit Court
4
............................................................................................................................................ [ ] Juvenile and Domestic Relations District Court

In re: 5
.........................................................................................................................................................................................................................................................
NAME OF CHILD

6
..................................................................................................... [ ] Putative 7
...........................................................................................................
NAME OF FATHER NAME OF MOTHER

Present: [ ] Mother ....................................................................................... [ ] Mother’s attorney ..................................................................................

[ ] Father ......................................................................................... [ ] Father’s attorney ....................................................................................
8 [ ] Child .......................................................................................... [ ] Guardian ad litem ..................................................................................
[ ] Agency Representative ........................................................ [ ] Agency Attorney ...................................................................................
[ ] Foster Parent(s) ...................................................................... [ ] CASA ........................................................................................................
[ ] Other .......................................................................................... [ ] Other ..........................................................................................................
9
A PETITION FOR FOSTER CARE REVIEW HEARING was filed on .......................................................................... . A hearing has been
DATE
held to review and approve the foster care plan pursuant to Va. Code §§ 16.1-282, 16.1-282.1 A2, or 16.1-282.2.
THE COURT FINDS THAT THE CHILD IS WITHIN THE JURISDICTION OF THIS COURT AND, BASED UPON A
PREPONDERANCE OF THE EVIDENCE, FINDS AS FOLLOWS:
1. Service of process was secured as to the parents for this hearing:
[ ] mother [ ] father appeared this date and expressly waived objections to service or accepted service without objection.
[ ] mother [ ] father served by personal service for this hearing.
10 [ ] mother [ ] father served by substituted service for this hearing.
[ ] mother [ ] father served by order of publication.
[ ] mother [ ] father is without the Commonwealth and was served by certified mail, return receipt requested.
[ ] mother [ ] father’s residual parental rights regarding the child have been terminated and notice to the parent is not required.
OR
[ ] the identity of the [ ] mother [ ] father is not reasonably ascertainable.
OR
[ ] reasonable efforts have been made to locate the [ ] mother [ ] father, who cannot be found.

2. Notice of this hearing and a copy of the petition for foster care review hearing pursuant to Virginia Code § 16.1-282 or § 16.1-
282.1 D was sent by the Court to the:
[ ] child, if 12 or older [ ] guardian ad litem for child
11 [ ] mother [ ] attorney for mother
[ ] father [ ] attorney for father
[ ] person standing in loco parentis [ ] attorney for person standing in loco parentis
[ ] foster parent(s) [ ] other ....................................................................................................................................................

3. The above-named child:

[ ] has been placed through an agreement with the local board of social services where legal custody remains with the parents or
guardian,
OR
12 [ ] is in the legal custody of the local board of social services or child welfare agency.

FORM DC-555 (MASTER, PAGE 1 OF 4) 07/14

Form DC-555 FOSTER CARE REVIEW ORDER Form DC-555

Data Elements, page one

1. Insert court case number.

2. Insert public or private child-placing agency case number.

3. Insert date of hearing at which this order is entered.

4. Insert name of court and check appropriate box.

5. Insert name of child who is subject of case.

6. Insert name of father. Check the box if paternity has not been established.

7. Insert name of mother.

8. Check boxes to indicate the persons present at the hearing and insert the names of those
present.

9. Insert date on which the petition for this foster care review hearing was filed.

10. Check the appropriate box for the service received by or reason why service was not
provided to the child’s mother and father.

11. Check appropriate boxes to indicate who was sent a copy of the petition.

12. Check appropriate box to indicate whether legal custody remains with the parents or has been
transferred to a public or private child-placing agency.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
Court Case No. 1
.........................................................................
2
Transfer of custody or placement occurred on ................................... to 3
................................................................................................
DATE PUBLIC OR PRIVATE CHILD-PLACING AGENCY
as a result of:
[ ] a court order in abuse or neglect case.
[ ] a court order in case of child at risk of abuse or neglect by a parent or custodian who has been adjudicated as
having abused or neglected another child in the care of the parent or custodian.
4 [ ] an entrustment agreement by parent(s).
[ ] a court order in relief of custody case.
[ ] a court order in [ ] child in need of services case or [ ] child in need of supervision case or
[ ] status offense case or [ ] delinquency case.
[ ] a placement agreement with parents or guardian.
[ ] other: ...............................................................................................................................................................................................................
THE COURT FURTHER FINDS THAT:
4. [ ] The above-named child is the subject of a foster care review hearing pursuant to Virginia Code § 16.1-282
because a foster care plan was filed in this court pursuant to Virginia Code § 16.1-281 and, since the
dispositional hearing held on .............................. at which the foster care plan was reviewed, the child has been:
DATE
[ ] placed through an agreement with the board of social services where legal custody remains with the
parents or guardian and such agreement has not been dissolved by court order; or
[ ] in the legal custody of the board or child welfare agency and the child has not had a petition to
terminate parental rights granted, filed or ordered to be filed on his or her behalf; has not been placed
in permanent foster care; or is age 16 or over and the plan for the child is not independent living.
OR
5 [ ] The above-named child is the subject of a semi-annual foster care review hearing pursuant to Virginia Code
§ 16.1-282.1 A2 because a hearing was held on ............................................... and placement of the child in
DATE
another planned permanent living arrangement was approved as the plan for the child for a maximum of 6 months.
OR
[ ] The above-named child is the subject of an annual foster care review hearing pursuant to Virginia Code § 16.1-282.2
because a hearing was held on ............................................ , the child remains in the legal custody of the board or
DATE
agency, and the child:
[ ] has had a petition to terminate parental rights granted, filed or ordered to be filed on his or her behalf; or
[ ] is placed in permanent foster care; or
[ ] has been admitted to the United States as a refugee or asylee and is age 16 or over and the plan for the
child is independent living.
AND
5. With reference to the foster care plan with the goal of 6
....................................................................................................... filed
FOSTER CARE PLAN GOAL
in this case and based upon [ ] the facts contained in the plan, which is incorporated by reference
[ ] the following facts:
7
...........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................

THE COURT FURTHER FINDS THAT:

[ ] Reasonable efforts [ ] have been made [ ] have not been made by the agency to reunite the child with his or her
parents, guardian, or other person standing in loco parentis to the child.
[ ] Reasonable efforts to reunite the child with the parents are not required pursuant to Va. Code § 16.1-281 B.
[ ] Another planned permanent living arrangement having been approved as the plan for the child, reasonable efforts
[ ] have been made [ ] have not been made to place the child in a timely manner in accordance with the foster
8 care plan and reasonable efforts [ ] have been made [ ] have not been made to monitor the child’s status in
another planned permanent living arrangement.
[ ] Reasonable efforts [ ] have been made [ ] have not been made by the agency to place the child in a timely manner in
accordance with the foster care plan and to complete the steps necessary to finalize the permanent placement of the
child.
FORM DC-555 (MASTER, PAGE 2 OF 4) 07/14
Form DC-555 FOSTER CARE REVIEW ORDER Form DC-555

Data Elements, page two

1. Insert court case number.

2. Insert date on which placement was made or legal custody was transferred.

3. Insert name of public or private child-placing agency to which custody was transferred or
with which child was placed.

4. Check the box that corresponds with the reason why child’s legal custody was changed or
why child was placed with a public or private child-placing agency.

5. Check appropriate box(es) to indicate why a review hearing is being held and the child’s
current status in foster care, and insert date of previous hearing.

6. Insert foster care plan goal.

7. Check applicable box to indicate basis for the reasonable efforts finding made below in
this section number 5 and specify facts on lines provided, as appropriate.

8. Check applicable box(es).

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
Case No. 1
......................................................................................

THE COURT, IN ACCORDANCE WITH THE BEST INTEREST OF THE CHILD, ORDERS THE FOLLOWING:

6. The foster care plan is:

2 [ ] approved as submitted and incorporated by reference.
OR

3 [ ] approved with the following revisions and, as revised, is incorporated by reference: ............................................................
.....................................................................................................................................................................................................................................
The clerk shall send a copy of any revisions to all persons who received that part of the original plan.
OR

4 [ ] disapprove and a new petition and plan shall be submitted to the court by ...................................................................................
DATE
for a hearing on ........................................................................ at .............................................. .
DATE TIME

7. [ ] Custody of the child is transferred to 5

6 [ ] As legal custody of the child is transferred to a relative other than the child’s prior family, district court form
DC-559, SUPPLEMENT TO ORDER TRANSFERRING CUSTODY, is attached and incorporated in this order.

7 8. [ ] .....................................................................................................................................................................................................................................
PUBLIC OR PRIVATE CHILD-PLACING AGENCY
shall continue to utilize reasonable efforts in making appropriate service referrals to the parents, child and foster parents
as applicable to accomplish the goals set forth in the foster care plan approved herein and orders of the court entered
herein. The parents shall continue to utilize their best efforts to fulfill the requirements of the foster care plan approved
herein and orders of the court entered herein.

8 9. [ ] A permanency planning hearing pursuant to Virginia Code § 16.1-282.1 shall be held on ......................................................
DATE
at ............................................... , and
TIME

............................................................................................................................. shall file a petition for permanency planning hearing

PUBLIC OR PRIVATE CHILD-PLACING AGENCY

and a foster care plan pursuant to Virginia Code § 16.1-282.1 by .....................................................................................................

DATE

9 [ ] Placement of the child in another planned permanent living arrangement having been approved as the plan for the
child for a maximum of 6 months, pursuant to Virginia Code § 16.1-282.1 A2 a foster care review hearing shall be
held on ...................................................... at ............................ , and ................................................................................................................
DATE TIME PUBLIC OR PRIVATE CHILD-PLACING AGENCY

shall file a petition for foster care review hearing and a foster care plan by ...................................................................................
DATE

FORM DC-555 (MASTER, PAGE 3 OF 4) 07/14

Form DC-555 FOSTER CARE REVIEW ORDER Form DC-555

Data Elements, page three

1. Insert court case number.

2. Check box to indicate if foster care plan is approved as submitted.

3. Check box, if applicable, and document revisions to the foster care plan.

4. Check this box if foster care plan disapproved and insert date new plan to be submitted
and date and time of next hearing.

5. Check box, if applicable, and insert name of public or private child-placing agency or
individual, and address.

6. Check box, if applicable.

7. Check box and insert name of public or private child-placing agency providing services
to the child and family, if applicable.

8. Check box if applicable and insert date and time of permanency planning hearing, name
of public or private child-placing agency, and date by which petition must be filed.

9. Check box if another planned permanent living arrangement is the goal, insert date and
time for foster care review hearing, insert name of public or private child-placing agency,
and insert the date by which that agency shall file a petition for foster care review hearing
and a foster care plan.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
Court Case No. 1
.........................................................................

2 [ ] As the child is in the legal custody of the board or child welfare agency and has had a petition to terminate
parental rights granted, filed or ordered to be filed on his or her behalf; is placed in permanent foster care;
or has been admitted to the United States as a refugee or asylee and is age 16 or over and the plan for the
child is independent living, and annual foster care review hearing pursuant to Virginia Code § 16.1-282.2
shall be held on

.................................................... at ............................. m., and .........................................................................................................

DATE TIME PUBLIC OR PRIVATE CHILD-PLACING AGENCY

shall file a petition for foster care review hearing and a foster care plan by .................................................................
DATE

3 [ ] As termination of parental rights has been ordered but a final order of adoption has not been entered on
behalf of the child, .......................................................................................................................................................... shall file
PUBLIC OR PRIVATE CHILD-PLACING AGENCY
an Adoption Progress Report pursuant to Virginia Code § 16.1-277.01 E, 16.1-277.02 D, § 16.1-278 E or
or § 16.1-283 F in six months, on ..........................................................................
DATE

4 10. [ ] Other: .....................................................................................................................................................................................................

5 11. [ ] This order having been entered in the ............................................................................................................ Circuit Court,
CITY OR COUNTY

this matter is referred pursuant to Virginia Code § 16.1-297 to the .................................................................................

CITY OR COUNTY
Juvenile and Domestic Relations District Court for future proceedings.

6
..................................................................... 7
_______________________________________________________________
DATE JUDGE

FORM DC-555 (MASTER, PAGE 4 OF 4) 07/14

Form DC-555 FOSTER CARE REVIEW ORDER Form DC-555

Data Elements, page four

1. Insert court case number.

2. Check box if applicable and insert date and time of annual foster care review hearing and
name of public or private child-placing agency and date PETITION FOR FOSTER CARE
REVIEW HEARING, DC-554, and a foster care plan, must be filed.

3. Check box if adoption is the goal and insert name of public or private child-placing
agency and the date by which that agency shall file an adoption progress report.

4. Check box and insert other orders the court might have.

5. For use by a circuit court referring the case back to the juvenile and domestic relations
district court.

6. Insert date signed by judge.

7. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
Form DC-556 PETITION FOR PERMANENCY PLANNING HEARING Form DC-556

Using This Form

1. Copies
a. Original – to court.
b. Copy – sent by the court to the child, if s/he is twelve years of age or older.
c. Copy – sent by the court to the guardian ad litem for the child.
d. Copy – sent by the court to each parent, unless parental rights have been terminated.
e. Copy – sent by the court to any person standing in loco parentis to the child at the time the
agency obtained custody or placed the child.
f. Copy – sent by the court to the person or agency with custody of the child or placement
responsibility for the child.
g. Copy – sent by the court to the attorney for the person or agency with custody of the child or
placement responsibility for the child.
h. Copy – sent by the court to the foster parent or foster parents or other care providers of the
child, except the section of the foster care plan describing the reasons why the child cannot be
returned home and the alternative chosen.
i. Copy – sent by the court to such other persons as the court may direct, including but not limited
to pre-adoptive parents, if any.
2. Prepared and filed by the public or private child-placing agency with custody or placement
responsibility for the child.
3. Attachments
a. Foster Care Plan (Agency Form).
b. Permanent Foster Care Agreement (Department of Social Services Form), as appropriate.
c. Court form DC-510, SUMMONS, if the parent or guardian of the child did not appear at the foster
care review hearing held pursuant to Va. Code § 16.1-282 and was not noticed to return for the
permanency planning hearing.
d. Court form DC-512, NOTICE OF HEARING.
4. Preparation details
a. It is suggested that the agency with custody of or placement responsibility for the child should
provide the court with enough copies of the petition and foster care plan for service or notice to
the parties.
b. The copy sent to the child should be to his or her own address, not the custodial or placement
agency’s address.
c. A parent whose residual parental rights to the child have been terminated should not be sent a
copy of the petition or foster care plan.
d. It is possible that form DC-511, PETITION, requesting termination of residual parental rights has
been filed at the same time as the PETITION FOR PERMANENCY PLANNING HEARING. If so,
follow the DISTRICT COURT MANUAL instructions (Chapter IX of the Text Volume) on notice
of such a petition to the appropriate parties.

DISTRICT COURT MANUAL FORMS MANUAL

JULY 2013
PETITION FOR PERMANENCY PLANNING HEARING 1
Court Case No. .........................................................................
Commonwealth of Virginia Va. Code §§ 16.1-282.1, 63.2-906
2
Agency Case No. .....................................................................

In re: 4
..........................................................................................................................................................................................................................................................
NAME OF CHILD

[ ] Male
5
.........................................................................................................
6 [ ] Female 7
.........................................................................................................
AGE (YEARS/MONTHS) DATE OF BIRTH

who was placed in the custody of or through an agreement with

8
................................................................................................................................................................................ on 9
...............................................................................
PUBLIC OR PRIVATE CHILD-PLACING AGENCY DATE

I, the undersigned Petitioner, state under oath to the best of my knowledge and belief that the following are true:

1. The above-named child is the subject of a permanency planning hearing pursuant to Virginia Code § 16.1-282.1
because:
[ ] (a) the child
i. was the subject of a foster care plan filed in this court pursuant to Virginia Code § 16.1-281, has not
previously been the subject of a permanency planning hearing at which the court approved a permanent
goal, and

ii. has been:

[ ] placed through an agreement with the local board of social services where legal custody remains with
the parents or guardian and such agreement has not been dissolved by court order; or

10 [ ] in the legal custody of the local board of social services or a child welfare agency and the child has
not had a petition to terminate parental rights granted, filed or ordered to be filed on his/her behalf;
has not been placed in permanent foster care; or is age 16 or over and the plan for the child is not
independent living.
OR
[ ] (b) the child was the subject of a hearing at which the Court made a determination that reasonable efforts to reunite
the child with parents are not required, in accordance with the provisions of Virginia Code § 16.1-281 B.
OR
[ ] (c) the child was the subject of a permanency planning hearing pursuant to Virginia Code § 16.1-282.1 at which
the Court approved an interim plan for the child.
OR
[ ] (d) the child has been placed in another planned permanent living arrangement and his/her need for long-term
residential treatment for a disabling condition is eliminated such that a permanency planning hearing is
required pursuant to Virginia Code § 16.1-282.1 A2.
12
11 2. [ ] A new foster care plan that identifies a permanent goal of ................................................................................................................. for
PERMANENT GOAL
review at this permanency planning hearing is attached hereto and incorporated herein;

FORM DC-556 (MASTER, PAGE 1 OF 3) 07/09

Form DC-556 PETITION FOR PERMANENCY PLANNING HEARING Form DC-556

Data Elements, page one

1. Insert court case number.

2. Insert public or private agency case number.

3. Insert name of court.

4. Insert name of child who is the subject of the case.

5. Insert age of child.

6. Check appropriate box for gender of child.

7. Insert date of birth of child.

8. Insert name of public or private child-placing agency with custody or placement responsibility
for the child.

9. Insert date on which child was placed with public or private child-placing agency.

10. Check appropriate box(es) to indicate reason why a permanency planning hearing is required.

11. Check box if this is a new foster care plan that identifies a permanent goal.

12. Insert permanent goal on line provided.

DISTRICT COURT MANUAL FORMS MANUAL

JULY 2013
1
Court Case No. .........................................................................
AND
.
[ ] (a) the board or agency seeks to achieve the permanent goal for the child and, therefore, petitions the court for the
following relief:
[ ] transfer custody of child to his/her prior family, namely
......................................................................................................................................................................................................................................................
NAME

[ ] dissolve the board’s placement agreement and return the child to his/her prior family.
.

[ ] transfer custody of the child to a relative other than the child’s prior family, namely
......................................................................................................................................................................................................................................................
2 NAME

[ ] approve termination of residual parental rights as being in the best interest of the child, and, upon separate
petitions [ ] filed [ ] to be filed, terminate residual parental rights pursuant to Virginia Code § 16.1-277.01 or
§ 16.1-283.
[ ] place child in permanent foster care. [ ] A permanent foster care agreement is appended.
[ ] direct the agency with custody of the child to provide the child with services to transition to independent living if
the child has been admitted to the United States as a refugee or asylee, has attained the age of 16 years and the
plan is independent living; OR
[ ] place the child in another planned permanent living arrangement.
OR
[ ] (b) The board or agency has thoroughly investigated the feasibility of the alternatives listed in Virginia Code § 16.1-
282.1 A (i) – (v) and alleges that none of these alternatives is in the best interest of the child and, therefore,
petitions the court for approval of an interim plan and the following relief:
.

3 [ ] continue custody with the board or agency or continue placement with the board through a parental
agreement; or
[ ] transfer custody to the board or agency from the parents or guardian of a child who has been in foster care
through an agreement where the parents or guardian retained legal custody.
.

4 3. [ ] If 2(b) above is applicable, the foster care plan pursuant to Virginia Code § 16.1-282.1 B includes provisions for
accomplishing the permanent goal within 6 months, and summarizes the investigation conducted of the
alternatives listed in Virginia Code § 16.1-282.1 A (i) – (v) and states why achieving each of these is not in the
best interest of the child at this time.

Wherefore, Petitioner requests that the court grant the following relief and such other relief as the child’s best
interest requires:

5 1. [ ] Docket the case for a permanency planning hearing to be held within thirty days, since a hearing was not
previously scheduled pursuant to Virginia Code § 16.1-281 B, 16.1-282 E, or § 16.1-282.1 B.
2. Provide notice of the hearing and a copy of the petition, pursuant to Virginia Code §§ 16.1-282.1 and 16.1-282, to the
following at addresses provided on the attached transmittal form:
• Child, if he/she is 12 years of age or older;
• Guardian ad litem for child;
• Child’s parents and any person standing in loco parentis at time agency assumed custody;
• Foster parents or other care providers of the child;
• Petitioning board of social services or other child welfare agency; and
• Such other persons as the court may direct, including, but not limited to, pre-adoptive parents, if any.

FORM DC-556 (MASTER, PAGE 2 OF 3) 07/13

Form DC-556 PETITION FOR PERMANENCY PLANNING HEARING Form DC-556

Data Elements, page two

1. Insert court case number.

2. Check boxes, if applicable, to propose achieving the child’s permanent goal and insert the
indicated name, as appropriate.

3. Check box, if applicable, to indicate proposed interim plan for the child.

4. Check box, if applicable.

5. Check box if hearing was not previously scheduled.

DISTRICT COURT MANUAL FORMS MANUAL

JULY 2013
1
Court Case No. .........................................................................

3. Enter a finding that:

[ ] Reasonable efforts [ ] have been made [ ] have not been made by the agency to reunite the child with his or her
parents, guardian or other person standing in loco parentis to the child.

2 [ ] Reasonable efforts to reunite the child with parents are not required pursuant to Virginia Code § 16.1-281 B.

[ ] The board or agency has identified a permanent goal for the child other than returning the child home and
reasonable efforts
[ ] have been made [ ] have not been made to achieve the permanent goal identified in the foster care plan.

4. Enter an order of disposition that adopts and approves the attached foster care plan for the child.

5. [ ] Schedule a future hearing date and give notice to all parties of the following:

[ ] a second permanency planning hearing pursuant to Virginia Code § 16.1-282.1 B to be held within six months
of this permanency planning hearing, if a continuation of foster care is the interim plan for the child.
3
[ ] a foster care review hearing in 6 months pursuant to Virginia Code § 16.1-282.1 A2 to review the foster care
plan for a child who is placed in another planned permanent living arrangement.

[ ] an annual foster care review hearing within 12 months pursuant to Virginia Code § 16.1-277.01 E, § 16.1-
277.02 D, § 16.1-278.3 E, or § 16.1-283 F.

4
...........................................................................................................................
PUBLIC OR PRIVATE CHILD-PLACING AGENCY

5
......................................................................................................... _____________________________________________________________ 6
DATE PETITIONER

Subscribed and sworn to before me this 7

............................................. _____________________________________________________________ 8
DATE [ ] INTAKE OFFICER [ ] CLERK

FOR NOTARY PUBLIC’S USE ONLY:

9
State of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] City [ ] County of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Acknowledged, subscribed and sworn to before me this . . . . . . . . . . . . . . day of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , 20 . . . . . . . . . . . . . . . .

............................................................... ________________________________________________________________
NOTARY REGISTRATION NUMBER NOTARY PUBLIC
(My commission expires: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . )

FORM DC-556 (MASTER, PAGE 3 OF 3) 07/08

Form DC-556 PETITION FOR PERMANENCY PLANNING HEARING Form DC-556

Data Elements, page three

1. Insert court case number.

2. Check box(es) to indicate the requested findings.

3. Check box(es) to indicate requested future necessary events.

4. Insert name of petitioning public or private child-placing agency.

5. Insert date signed by petitioner.

6. Signature of petitioner.

7. Insert date sworn/affirmed.

8. Signature of intake officer or clerk. Check box to indicate title.

9. If acknowledgement taken by notary public, all enclosed fields must be completed, including
notary’s registration number and commission expiration date.

DISTRICT COURT MANUAL FORMS MANUAL

JULY 2013
Form DC-557 PERMANENCY PLANNING ORDER Form DC-557

Using This Form

1. Copies

a. Original - for the court.

b. Copy - to the child, if s/he is twelve years of age or older.
c. Copy - to the guardian ad litem for the child.
d. Copy - to each parent, unless parental rights have been terminated.
e. Copy - to any person standing in loco parentis to the child at the time the agency obtained
custody or placed the child.
f. Copy - to the person or agency with custody of the child or placement responsibility for the child.
g. Copy - to the attorney for the person or agency with custody of the child or placement
responsibility for the child.
h. Copy - to the foster parent or foster parents or other care providers of the child.
i. Copy - to such other persons as the court may direct, including but not limited to pre-adoptive
parents, if any.
j. Copy - to all attorneys of record not listed above.

2. Preparation of the Order

a. Numbers 1-4 prepared by clerk.

b. Numbers 5-10 prepared by judge.
c. Signed by judge.
d. Alternatively, numbers 1-10 prepared by clerk, signed by judge.

3. Attachments

a. DC-559, SUPPLEMENT TO ORDER TRANSFERRING CUSTODY, as appropriate

b. DC-531, ORDER FOR INVOLUNTARY TERMINATION OF RESIDUAL PARENTAL RIGHTS, as
appropriate.
c. DC-534, ORDER FOR VOLUNTARY TERMINATION OF RESIDUAL PARENTAL RIGHTS, as
appropriate.
d. DC-558, PERMANENT FOSTER CARE PLACEMENT ORDER, as appropriate.
e. DC-508, ACKNOWLEDGEMENT OF NEXT HEARING DATE, as appropriate.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
Form DC-557 PERMANENCY PLANNING ORDER Form DC-557

Using This Form, continued

4. Preparation Details

a. Note that the information required in section number 3 of the DC-557, PERMANENCY PLANNING
ORDER, on placement or transfer of custody and the reason for the child’s placement in foster
care, may be found on page 2 at section number 1 of the DC-553, DISPOSITIONAL ORDER FOR
UNDERLYING PETITION, FOSTER CARE PLAN. The information on placement or transfer of
custody may also be found at the top of the DC-556, PETITION FOR PERMANENCY PLANNING
HEARING.
b. Note that the information required in section number 4 of the DC-557, PERMANENCY PLANNING
ORDER, on the reason the child is the subject of a permanency planning hearing, may be found in
section number 1 of the DC-556, PETITION FOR PERMANENCY PLANNING HEARING.
c. Section number 5 must be completed in all cases.
d. Complete section number 6, 7 or 8.
e. At the conclusion of the permanency planning hearing, set a date within 6 months of this hearing
for the second permanency planning hearing, if the permanent goal for the child was not achieved
at the initial permanency planning hearing.
f. If the permanent goal for the child was not achieved at this hearing, set a date 30 days before the
next scheduled hearing by which the agency must file the DC-556, PETITION FOR PERMANENCY
PLANNING HEARING.
g. If the goals of permanent foster care or independent living are approved at the permanency
planning hearing, schedule a date for a foster care review hearing to be held in 12 months from
the permanency planning hearing, and a date 30 days prior to the next scheduled hearing for the
filing of a DC-554, PETITION FOR FOSTER CARE REVIEW HEARING by the agency.
h. If the adoption goal is approved at the permanency planning hearing, schedule a date for a foster
care review hearing to be held in 12 months from the permanency planning hearing, and a date 30
days prior to the next scheduled date for the filing of a DC-554, PETITION FOR FOSTER CARE
REVIEW HEARING, by the agency.
i. If termination of parental rights is ordered, schedule a date in 6 months for the agency to file an
Adoption Progress Report.
j. Future hearing and filing dates and times should be entered at section number 9 on page 4 of 5 or
on page 5 of 5.
k. If custody of the child is transferred to a relative other than the child’s prior family, enter a DC-
559, SUPPLEMENT TO ORDER TRANSFERRING CUSTODY.

l. If the child is placed in a permanent foster care placement as a result of the permanency planning
hearing, enter a DC-558, PERMANENT FOSTER CARE PLACEMENT ORDER in addition to the DC-
557, PERMANENCY PLANNING ORDER at the conclusion of the permanency planning hearing. If
so, there is no need to schedule any future hearing dates.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
Form DC-557 PERMANENCY PLANNING ORDER Form DC-557

Using This Form, continued

m. The Court Improvement Program suggests entry of the orders in the courtroom at the conclusion
of the permanency planning hearing, and copies of the orders and the DC-508, as appropriate,
provided before leaving the court building to all persons who received a copy of the PETITION
FOR PERMANENCY PLANNING HEARING.

n. A copy of the DC-508, ACKNOWLEDGEMENT OF NEXT HEARING DATE, should not be provided to
a parent whose parental rights to the child have been terminated.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
PERMANENCY PLANNING ORDER 1
Court Case No. .....................................................................................
Commonwealth of Virginia Va. Code §§ 16.1-282.1, 63.2-906 2
Agency Case No. .................................................................................
3
.....................................................................................................................
DATE OF HEARING

4 [ ] Circuit Court
............................................................................................................................................ [ ] Juvenile and Domestic Relations District Court
5
In re: ............................................................................................................................................................................................................................................................
NAME OF CHILD
6
............................................................................................................... [ ] Putative 7
...............................................................................................................
NAME OF FATHER NAME OF MOTHER

Present: [ ] Mother ....................................................................................... [ ] Mother’s attorney .................................................................................

A permanency planning hearing has been held pursuant to Virginia Code § 16.1-282.1. THE COURT FINDS THAT THE CHILD
IS WITHIN THE JURISDICTION OF THIS COURT AND, BASED UPON A PREPONDERANCE OF THE EVIDENCE,
FINDS AS FOLLOWS:

1. Service of process was secured as to the parents for this hearing:

[ ] mother [ ] father appeared this date and expressly waived objections to service or accepted service without objection.
[ ] mother [ ] father served by personal service for this hearing.
[ ] mother [ ] father served by substitute service for this hearing.
[ ] mother [ ] father served by order of publication.
10 [ ] mother [ ] father is without the Commonwealth and was served by certified mail, return receipt requested.
OR
[ ] the identity of the [ ] mother [ ] father is not reasonably ascertainable.
OR
[ ] reasonable efforts have been made to locate the [ ] mother [ ] father, who cannot be found.
2. Notice of this hearing and a copy of the petition filed pursuant to Virginia Code § 16.1-282.1 was sent by the court to the:
[ ] child, if 12 or older [ ] guardian ad litem for child

11 [ ] mother [ ] attorney for mother

[ ] father [ ] attorney for father
[ ] person standing in loco parentis [ ] attorney for person standing in loco parentis
[ ] foster parent(s) [ ] other ..........................................................................................................................................

FORM DC-557 (MASTER, PAGE 1 OF 5) 07/14

Form DC-557 PERMANENCY PLANNING ORDER Form DC-557

Data Elements, Page 1 of 5

1. Insert court case number.

2. Insert public or private child-placing agency case number.

3. Insert date on which hearing is held.

4. Insert name of court and check appropriate box.

5. Insert name of child who is subject of case.

6. Insert name of father. Check box if paternity has not been established.

7. Insert name of mother.

8. Insert names on dotted lines and check boxes for individuals present at the hearing.

9. Insert date petition for permanency planning hearing was filed with the court.

10. Check the appropriate box for the service received by or reason why service was not
provided to the child’s mother and father.

11. Check appropriate boxes to indicate who was sent a copy of the petition and notice of the
hearing.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
1
Court Case No. .....................................................................................

THE COURT FURTHER FINDS THAT:

3. The above-named child:

[ ] has been placed through an agreement with the local board of social services where legal custody remains with the parents or
2 guardian,
OR
[ ] is in the legal custody of the local board of social services or child welfare agency.
3
Transfer of custody or placement occurred on ........................................ 4
to ....................................................................................................................
DATE PUBLIC OR PRIVATE CHILD-PLACING AGENCY
as a result of:
[ ] a court order in abuse or neglect case.
[ ] a court order in case of a child at risk of abuse or neglect by a parent or custodian who has been adjudicated as having abused
or neglected another child in the care of the parent or custodian.
[ ] an entrustment agreement by parent(s).
5
[ ] a court order in relief of custody case.
[ ] a court order in [ ] child in need of services case or [ ] child in need of supervision case or [ ] status offense case or
[ ] delinquency case.
[ ] a placement agreement with parents or guardian.
[ ] Other: ........................................................................................................................................................................................................................................

4. [ ] The above-named child is the subject of a permanency planning hearing pursuant to Virginia Code § 16.1-282.1 because:
[ ] (a) the child
i. was the subject of a foster care plan filed in this court pursuant to Virginia Code § 16.1-281, has not previously
been the subject of a permanency planning hearing at which the court approved a permanent goal, and
ii. has been:
[ ] placed through an agreement with the local board of social services where legal custody remains with the
parents or guardian and such agreement has not been dissolved by court order; or
[ ] in the legal custody of the local board of social services or a child welfare agency and the child has not had
a petition to terminate parental rights granted, filed or ordered to be filed on his/her behalf; has not been
6 placed in permanent foster care; or is age 16 or over and the plan for the child is not independent living.
OR
[ ] (b) the child was the subject of a hearing at which the Court made a determination that reasonable efforts to reunite the
child with his or her parents are not required, in accordance with the provisions of Virginia Code § 16.1-281 B.
OR
[ ] (c) the child was the subject of a permanency planning hearing pursuant to Virginia Code § 16.1-282.1 at which the
Court approved an interim plan for the child.
OR
[ ] (d) the child has been placed in another planned permanent living arrangement and his/her need for long-term
residential treatment for a disabling condition is eliminated such that a permanency hearing is required pursuant to
Virginia Code § 16.1-282.1 A2.

FORM DC-557 (MASTER, Page 2 of 5) 07/14

Form DC-557 PERMANENCY PLANNING ORDER Form DC-557

Data Elements, Page 2 of 5

1. Insert court case number.

2. Check appropriate box to indicate whether legal custody remains with the parents or has been
transferred to a public or private child-placing agency.

3. Insert date on which placement was made or legal custody was transferred.

4. Insert name of the public or private child-placing agency to which custody was transferred or
with which child was placed.

5. Check the box that corresponds with the reason why child’s legal custody was changed or
why child was placed with the public or private child-placing agency.

6. Check appropriate boxes to indicate why a permanency planning hearing is being held.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
1
Court Case No. .....................................................................................

2
Having reviewed the foster care plan with the permanent goal of ................................................................................................................................
PERMANENT GOAL
and given consideration to the best interest of the child, the court’s determinations are specified below with regard to
reasonable efforts in paragraph 5, and the foster care plan in paragraph 6, 7 or 8:
3
5. Based upon [ ] the facts contained in the plan, which is incorporated by reference [ ] the following facts: ............................................
3
...............................................................................................................................................................................................................................................................
...............................................................................................................................................................................................................................................................
[ ] Reasonable efforts [ ] have been made [ ] have not been made by the agency to reunite the child with his or her parents,
guardian or other person standing in loco parentis to the child.
4 [ ] Reasonable efforts to reunite the child with his or her parents are not required pursuant to Virginia Code § 16.1-281 B.
[ ] The board or agency has identified a permanent goal for the child other than returning the child home and reasonable efforts
[ ] have been made [ ] have not been made to achieve the permanent goal identified in the foster care plan.
AND
6. 5[ ] The permanent goal is achievable at this time, and the foster care plan is:
6 [ ] approved as submitted and incorporated by reference.
OR
7 [ ] approved with the following revisions and, as revised, is incorporated in this order: .....................................................................

7
.............................................................................................................................................................................................................................................

[ ] The board of social services’ placement agreement is dissolved and the child is returned to his or her prior family.
[ ] Custody of the child is transferred to a relative other than the child’s prior family, namely
10
.............................................................................................................................................................................................................................................
NAME AND ADDRESS

[ ] District court form DC-559, SUPPLEMENT TO ORDER TRANSFERRING CUSTODY, is attached and incorporated in this
order, as legal custody of the child is transferred to a relative other than the child’s prior family.
[ ] Termination of parental rights having been documented as being in the best interest of the child:
[ ] The agency with custody of the child is directed to file petitions to terminate parental rights pursuant to Virginia
11
Code § 16.1-277.01 or § 16.1-283 by ...........................................................................................................................................................
8
[ ] Upon separate petitions to terminate parental rights, the court has heard and adjudicated these petitions at this
proceeding to approve the foster care plan. Separate orders terminating parental rights are appended.
[ ] The child is placed in permanent foster care pursuant to Virginia Code § 63.2-908. A separate permanent foster care
placement order is appended.
[ ] As the child has been admitted to the United States as a refugee or asylee, has attained the age of 16 years and the plan is
independent living, the agency with custody of the child shall provide the child with services to transition to independent
living.
[ ] The child’s placement in another planned permanent living arrangement is approved for a maximum of 6 months, as:
• The child has a severe and chronic emotional, physical or neurological disabling condition; and
• The child requires long-term treatment for the disabling condition; and
• None of the alternatives listed above is achievable for the child at this time.

FORM DC-557 (MASTER, PAGE 3 OF 5) 07/13

Form DC-557 PERMANENCY PLANNING ORDER Form DC-557

Data Elements, Page 3 of 5

1. Insert court case number.

2. Insert child’s permanent goal.

3. Check applicable box to indicate basis for the reasonable efforts finding made below in this
section number 5 and specify facts on lines provided, as appropriate.

4. Check applicable box(es).

5. Check box, if applicable, to indicate that a permanent goal is achievable at this hearing.

6. Check box, if applicable, to indicate that the foster care plan is approved as submitted.

7. Check box, if applicable, and insert revisions to the foster care plan.

8. Check applicable box to indicate the permanent goal that is achieved.

9. Insert name of prior family if custody transferred to prior family.

10. Insert name and address of relative if custody transferred to relative.

11. Check box and insert date by which public or private child-placing agency is directed to file
termination of parental rights petition(s).

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
1
Court Case No. .....................................................................................

OR
7. 2[ ] The interim plan, which meets the requirements of Virginia Code § 16.1-282.1 B, is:
3[ ] approved for a maximum of 6 months and incorporated by reference.
OR
4[ ] approved with the following revisions for a maximum of 6 months and, as revised, is incorporated in this order:
.............................................................................................................................................................................................................................................

.............................................................................................................................................................................................................................................
AND
[ ] Custody of the child is continued with the board or child welfare agency or placement of the child is continued with the
5 board through a parental agreement. OR
[ ] Custody of the child is transferred to the board or child welfare agency from the parents or guardian of a child who has
been in foster care where the parents or guardian retained custody.
AND
Having approved the interim plan, the Court makes the following finding:
[ ] Since return home remains the plan for the child: (i) the parent has made marked progress toward reunification with the
child; (ii) the parent has maintained a close and positive relationship with the child; (iii) the child is likely to return home
6 in the near future, although it is premature to set the exact date for return at the time of this hearing. OR
[ ] Since return home is not the plan for the child: (i) marked progress is being made to achieve the permanent plan goal
identified by the board or child welfare agency; and (ii) it is premature to set an exact date for accomplishing this goal at
the time of this hearing.
OR
8. 7[ ] The foster care plan is disapproved and a new petition and plan shall be submitted to the Court on or before:
7
.............................................................................. 7
for a hearing on ................................................................................ 7
at ............................................. .
DATE DATE TIME

9. 8[ ] Approval of an interim plan having been ordered, a second permanency planning hearing to achieve the permanent goal by
entering an order consistent with Virginia Code § 16.1-282.1 A (i)-(v) shall be held within 6 months, on
8
.............................................................................. 8
at .............................................. , and
DATE TIME

8
.............................................................................................................................................................. shall file a petition for permanency planning
PUBLIC OR PRIVATE CHILD-PLACING AGENCY

8
hearing and a foster care plan by .................................................
DATE
9[ ] Placement of the child in another planned permanent living arrangement having been approved as the permanent plan for the
child for a maximum of 6 months, pursuant to Virginia Code § 16.1-282.1 A2 a foster care review hearing shall be held on
9
.............................................................................. 9
at .............................................. , and
DATE TIME

9
and a foster care plan by ............................................... .
DATE

FORM DC-557 (MASTER, Page 4 of 5) 07/14

Form DC-557 PERMANENCY PLANNING ORDER Form DC-557

Data Elements, Page 4 of 5

1. Insert court case number.

2. Check box, if applicable.

3. Check box if an interim plan is approved as submitted.

4. Check box, if applicable, and insert revisions to the interim foster care plan.

5. Check box, if applicable.

6. Check box, if applicable.

7. Check box to indicate that the foster care plan is disapproved and insert date by which a new
plan must be submitted and date and time for a hearing on the new plan.

8. Check box, if applicable, and insert date and time of second permanency planning hearing,
name of public or private child-placing agency and date by which petition and a foster care
plan must be filed.

9. Check box, if applicable, and insert date and time of semi-annual foster care review hearing,
the name of the appropriate public or private child-placing agency, and the date by which that
agency must file a petition for foster care review hearing and a foster care plan.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
1
Court Case No. .....................................................................................

2[ ] Termination of parental rights having been documented as in the best interest of the child and petitions therefor granted, filed
or ordered to be filed; or placement in permanent foster care or services to transition to independent living having been
ordered, pursuant to Virginia Code § 16.1-282.2 an annual foster care review hearing is set in twelve months, on
2
.............................................................................. 2
at .............................................. , and
DATE TIME

2
for foster care review hearing and a foster care plan by ............................................. .
DATE
3 3
[ ] Termination of parental rights having been ordered, ................................................................................................................................................
PUBLIC OR PRIVATE CHILD-PLACING AGENCY

shall file an Adoption Progress Report pursuant to Virginia Code § 16.1-277.01 E, § 16.1-277.02 D, § 16.1-278.3 E or

§ 16.1-283 F every six months until a final order of adoption is entered. The first report is due on ......................................................
DATE

10. 4[ ] Other: ......................................................................................................................................................................................................................................

4
...................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................

11. 5[ ] This order having been entered in the .................................................................................................

CITY OR COUNTY
Circuit Court, this matter is referred

pursuant to Virginia Code § 16.1-297 to the .......................................................................................... Juvenile and Domestic Relations
CITY OR COUNTY
District Court for future proceedings.

6
..................................................................................... _____________________________________________
7
DATE JUDGE

FORM DC-557 (MASTER, PAGE 5 OF 5) 07/14

Form DC-557 PERMANENCY PLANNING ORDER Form DC-557

Data Elements, page 5 of 5

1. Insert court case number.

2. Check box, if applicable, and insert date and time of annual foster care review hearing, the
name of the appropriate public or private child-placing agency, and the date by which that
department must file a petition for foster care review hearing and a foster care plan.

3. Check box, if applicable, and insert name of public or private child-placing agency and date
by which that agency must file an Adoption Progress Report.

4. Check box, if applicable, and insert other findings or orders of the court.

5. For use by a circuit court referring the case back to the juvenile and domestic relations
district court.

6. Date signed by judge.

7. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
Form DC-560 PETITION AND ORDER FOR Form DC-560
PARENTAL PARTICIPATION
Using this Form

1. Copies

a. Original - to the court.

b. First copy - parent who is subject to the order.

c. Second copy - school board/petitioner.

d. Other copies as determined by local practice.

2. Petition signed by petitioner or by intake officer. Order signed by judge

3. Attachments - none required.

4. Preparation details - this form is to be used for petitions filed by school boards against a parent
pursuant to Virginia Code ∋∋ 16.1-241.2 and 22.1-279.3.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2004
PETITION AND ORDER FOR PARENTAL PARTICIPATION Case No. 1
....................................................
Commonwealth of Virginia Va. Code §§ 16.1-241.2, 22.1-279.3

2
........................................................................
DATE OF HEARING

3
..................................................................................................................... Juvenile and Domestic Relations District Court

4
.............................................................................. v. 10
....................................................................................
PETITIONER/SCHOOL BOARD RESPONDENT/PARENT/GUARDIAN/LEGAL CUSTODIAN

ADDRESS
5
................................. ............................................ ...................................................................................
ADDRESS

.............................................................................. ...................................................................................

TELEPHONE NUMBER
6
.................................. .......................................... ...................................................................................
TELEPHONE NUMBER

.............................................................................. 11
...................................................................................
NAME OF STUDENT RESPONDENT’S DATE OF BIRTH

7
..............................................................................
12
...................................................................................
ADDRESS RESPONDENT’S SOCIAL SECURITY NUMBER

8
..............................................................................
9
STUDENT’S DATE OF BIRTH STUDENT’S SOCIAL SECURITY NUMBER

13
The school board for . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . hereby petitions this court to proceed against
the parent named above for willful and unreasonable refusal to participate in efforts to improve the student’s behavior. The school
board specifically requests that:

[ ] The court order the parent to meet with school officials to discuss the student’s improvement in behavior, school attendance
or educational progress, the school board’s standards of student conduct, and the parent’s responsibility to assist the school
in disciplining the student, maintaining order, or ensuring the child’s school attendance.

[ ] The court impose a civil penalty not to exceed $500.00 for the parent’s failure to meet with school officials due to the student’s
suspension or expulsion.
[ ] The court order the student or parent to participate in such programs or such treatment as the court deems appropriate to improve
the student’s behavior.

..............................................................................................................................................................................

[ ] The court order the student or parent to be subject to the conditions and limitations as the court deems appropriate for the
supervision, care, and rehabilitation of the student or his parents.
..............................................................................................................................................................................
SUGGESTED CONDITIONS AND LIMITATIONS

..............................................................................................................................................................................

.................... 15
....................... 16
______________________________________________________________
DATE PETITIONER’S SIGNATURE

Sworn/Affirmed and signed before me on ...............................................................

17
______________________________________________________________
INTAKE OFFICER

FORM DC-560 (MASTER, PAGE 1 OF 2) REVISED 07/04

Form DC-560 PETITION AND ORDER FOR Form DC-560
PARENTAL PARTICIPATION
Data Elements, front

1. Case number.

2. Name of court.

3. Hearing date and time.

4. Name of petitioning school board.

5. Address of petitioning school board.

6. Telephone number of petitioning school board.

7. Name and address of student.

8. Student's date of birth.

9. Student's social security number.

10. Name, address and telephone number of respondent/parent (or guardian).

11. Name of petitioning school board.

12. Relief sought by petitioner.

13. Date of petition.

14. Signature of representative of petitioner.

15. Space for intake officer's signature and date.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2004
ORDER

1
....................................................................................
PETITIONER/SCHOOL BOARD

2
....................................................................................
RESPONDENT/PARENT/GUARDIAN/LEGAL CUSTODIAN

The court hereby orders:

[ ] a civil fine of $ ....................................................... to be paid to ..........................................................................

[ ] The parent(s) to meet with school officials;

[ ] The [ ] student and/or [ ] parent to participate in the following program or treatment:

..............................................................................................................................................................................
PROGRAM NAME AND ADDRESS

3 ..............................................................................................................................................................................

[ ] The [ ] student and/or [ ] parent to be subject to the following conditions and limitations:

..............................................................................................................................................................................

4
................................................ 5
______________________________________________________________
DATE JUDGE

FORM DC-560 (MASTER, PAGE 2 OF 2) REVISED 07/04

Form DC-560 PETITION AND ORDER FOR Form DC-560
PARENTAL PARTICIPATION
Data Elements, reverse

1. Petitioner's name.

2. Respondent/Parent's name

3. Check box (es) reflecting disposition.

4. Date of order.

5. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2004
Form DC-561 ADJUDICATORY ORDER FOR Page: 1
ABUSE OR NEGLECT CASES

Using this Form

2. Preparation of the order

a. Top of page one through number 1 prepared by clerk.
b. Numbers 2-6 prepared by judge.
c. Signed by judge.
d. Alternatively, numbers 1-6 prepared by clerk, signed by judge.

3. Attachments
a. DC-527, PRELIMINARY CHILD PROTECTIVE ORDER, if entered in this case.
b. DC-528, PRELIMINARY REMOVAL ORDER, if entered in this case.
c. DC-508, ACKNOWLEDGEMENT OF NEXT HEARING DATE, if used.

4. Preparation details
a. This form may be used to adjudicate an abuse or neglect case at the hearing held
within 30 days of the hearing at which a party objected to adjudicating the allegations
of abuse or neglect.
b. This form may be used to adjudicate an abuse or neglect case at the preliminary removal hearing
or preliminary protective hearing, but if so, it does not replace the DC-528, PRELIMINARY
REMOVAL ORDER or the DC-528, PRELIMINARY REMOVAL ORDER.
c. If not previously done, at the conclusion of the hearing at which this order is entered, schedule a
dispositional hearing, which may be documented on page two at number 3. The dispositional
hearing should be held within 75 days of the preliminary hearing on the petition alleging abuse or
neglect.
d. If the child has been placed in foster care, set a date for the filing of the foster care plan, which
may be documented on page two at number 4. The foster care plan should be heard at the hearing
to dispose of the abuse or neglect petition.

If an order that was previously entered in this case is modified by this order, this order must be served on
the persons who received a copy of the prior order.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-561 ADJUDICATORY ORDER FOR Page: 2
ABUSE OR NEGLECT CASES

ADJUDICATORY ORDER FOR Court Case No.: . . . . . . . .1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ABUSE OR NEGLECT CASES Agency Case No.: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2. . . .
Commonwealth of Virginia Va. Code §§ 16.1-228, 16.1-241 (A)(2a), 16.1-252, 16.1-253
. . . . . . . . . . . . . . . .3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATE OF HEARING

..........................................................................................
4 [ ] Circuit Court
[ ] Juvenile and Domestic Relations District Court
5
In re: ..............................................................................................................................................................
NAME OF CHILD

. . . . . . . . . . . . . . . . . . .6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Putative .......................................................................

7
NAME OF FATHER NAME OF MOTHER

Present: [ ] Mother . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Mother’s attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

[ ] Father . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Father’s attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8 [ ] Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 [ ] Guardian ad litem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
[ ] Agency Representative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Agency Attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
[ ] Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] CASA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
A petition alleging that the child has been abused or neglected pursuant to Virginia Code § 16.1-241 (A)(1), or at risk of abuse or
neglect pursuant to Virginia Code § 16.1-241 (A)(2a), has been filed. THE COURT FINDS THAT THE CHILD IS WITHIN
THE JURISDICTION OF THIS COURT AND, BASED ON A PREPONDERANCE OF THE EVIDENCE, THE COURT
FURTHER FINDS AS FOLLOWS:
1. Proper notice of the adjudicatory hearing was provided by the court to the:
[ ] child, if 12 or older [ ] guardian ad litem for child
[ ] mother [ ] attorney for mother
[ ] father [ ] attorney for father
9 [ ] guardian or legal custodian [ ] attorney for guardian or legal custodian
[ ] person standing in loco parentis [ ] attorney for person standing in loco parentis
[ ] other [ ] other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. A hearing has been held for adjudication of the petition and:
a. [ ] The child is not abused or neglected as defined in Virginia Code § 16.1-228, or is not at risk of abuse or neglect as
10 provided in Virginia Code § 16.1-241 (A)(2a), and the petition is dismissed.
OR
[ ] The child is abused or neglected as defined in Virginia Code § 16.1-228; specifically, the child is one:
11
[ ] Whose parents or other person responsible for his care creates or inflicts, threatens to create or inflict, or allows to
be created or inflicted upon such child a physical or mental injury by other than accidental means, or creates a
substantial risk of death, disfigurement or impairment of bodily or mental functions.
[ ] Whose parents or other person responsible for his care neglects or refuses to provide care necessary for his health;
however, no child who in good faith is under treatment solely by spiritual means through prayer in accordance
with the tenets and practices of a recognized church or religious denomination shall for that reason alone be
considered to be an abused or neglected child.
[ ] Whose parents or other person responsible for his care abandons such child.
11
[ ] Whose parents or other person responsible for his care commits or allows to be committed any sexual act upon a
child in violation of the law.
[ ] Who is without parental care or guardianship caused by the unreasonable absence or the mental or physical
incapacity of the child's parent, guardian, legal custodian or other person standing in loco parentis.
OR
[ ] The child is at risk of being abused or neglected by a parent or custodian who has been adjudicated as having
12 abused or neglected another child in the care of the parent or custodian.

FORM DC-561 (MASTER, PAGE ONE OF TWO) 7/06

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-561 ADJUDICATORY ORDER FOR Page: 3
ABUSE OR NEGLECT CASES

Data Elements, Page One

1. Insert the court case number.

2. Insert the agency case number.

3. Insert the date of the hearing at which this order is entered.

4. Insert the city or county in which the court is located, and check the box to
indicate the court.

5. Insert the name of the child who is the subject of the petition alleging abuse
or neglect.

6. Insert the father’s name, and check the box if paternity has not been
established.

7. Insert the mother’s name.

8. Check the boxes to indicate who is present at the hearing, and insert the
names of those persons who are present.

9. Check the boxes to indicate who received notice of the hearing.

10. Check the box, if applicable.

11. Check the applicable boxes.

12. Check the box, if applicable.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-561 ADJUDICATORY ORDER FOR Page: 4
ABUSE OR NEGLECT CASES
1
Court Case No. .................................................

b. The court’s determinations supporting entry of this order are based upon:
[ ] the facts contained in the [ ] affidavit [ ] petition filed in this case, which is (are) incorporated by reference.
2
[ ] the following facts: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

..................................................................................................................................................

THE COURT ORDERS THE FOLLOWING:

3. [ ] As the child has been found to be abused or neglected, or at risk of abuse or neglect as provided in Virginia Code
3 § 16.1- 241 (A)(2a), a dispositional hearing pursuant to Virginia Code § 16.1-278.2 shall
be held on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . .3. . . . . . . . . m.
DATE TIME

4. [ ] As the child has been placed in foster care, at the dispositional hearing a foster care plan filed in accordance with
4 Virginia Code § 16.1-281 shall be reviewed by the court, and . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PUBLIC OR PRIVATE CHILD-PLACING AGENCY

shall file the foster care plan by ............................................................................................................

DATE

5. [ ] Other: .................................................................................................................................................
5
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

...........................................................................................................................................................

. . . . . . . . . . . . . . . .6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
__________________________________________________
DATE JUDGE

FORM DC-561 (MASTER, PAGE TWO OF TWO) 7/02

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-561 ADJUDICATORY ORDER FOR Page: 5
ABUSE OR NEGLECT CASES

Data Elements, Page Two

1. Insert the court case number.

2. Check the applicable box(es), and, as appropriate, specify on the lines provided on the facts
that substantiate the court’s finding on the child’s status as abused, neglected or at risk of
abuse or neglect.

3. If applicable, check the box and insert the date and time for the dispositional hearing.

4. If applicable, check the box, insert the date name of the public or private agency with custody
or placement responsibility for the child, and the date by which that agency shall file a foster
care plan.

5. Check the box and specify any other orders of the court on the lines provided, as appropriate.

6. Insert date on which this order is signed.

7. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-562 ORDER FOR CONTINUED CUSTODY Form DC-562
TRANSFER TO AGENCY

Using This Form

1. Copies

a. Original – for the court.

b. Copy – to the child, if s/he is twelve years of age or older.
c. Copy – to the guardian ad litem for the child.
d. Copy – to each parent, unless parental rights have been terminated.
e. Copy – to any person standing in loco parentis to the child at the time the agency
obtained custody or placed the child.
f. Copy – to the person or agency with custody of the child or placement responsibility for
the child.
g. Copy – to the attorney for the person or agency with custody of the child or placement
responsibility for the child.
h. Copy – to the Court Services Unit representative, if any.
i. Copy – to the attorney for the Commonwealth, if any.
j. Copy – to such other persons as the court may direct.
k. Copy – to all attorneys of record not listed above.

2. Preparation of the order

a. Top of page one through paragraph A, prepared by clerk.

b. Paragraphs B-J, prepared by judge.
c. Signed by judge.
d. Alternatively, paragraphs A-J, prepared by clerk, signed by judge.

3. Attachments

a. Any other order entered to dispose of the petition alleging that the child is in need of
services or supervision, delinquent, or a status offender.
b. District court form DC-508, ACKNOWLEDGMENT OF NEXT HEARING DATE, if used.

4. Preparation details

a. This form should be used to transfer custody of a child to an agency in cases in which the
child has been found to be in need of services or supervision, delinquent, or a status
offender.
b. This form should not be used to transfer custody to an individual.
c. Paragraph B on page one must be completed in its entirety, whether placing the child
temporarily in foster care or transferring legal custody to an agency.
d. If the child is temporarily placed in foster care without providing notice or an opportunity
to be heard to the relevant agency, set a date within 14 days for a hearing on this order
and provide notice to the agency.
e. Whether the child has been temporarily placed in foster care or legal custody transferred
to an agency, set a date for a hearing on the foster care plan and a date by which the
agency shall file a foster care plan.
f. A guardian ad litem should be appointed for the child, if not previously appointed.
g. The Court Improvement Program recommends that the court consider appointing
attorneys for the parents for the scheduled hearing on the foster care plan.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
ORDER FOR CUSTODY TRANSFER TO AGENCY 1
Case No. ......................................................................................
Va. Code §§ 16.1-278.4, 16.1-278.5, 16.1-278.6, 16.1-278.8
Commonwealth of Virginia 2
.........................................................................................................
DATE OF HEARING

3
............................................................................................................................................ Juvenile and Domestic Relations District Court

USING THIS FORM

• This form is to be used to transfer custody to a public or private child-placing agency in the following case types:
4 [ ] Child in need of Services [ ] Child in need of Supervision [ ] Delinquency [ ] Status Offense
• Indicate case type of this child’s case by check one of the boxes above.
• Do not use this form when ordering custody and/or visitation among individuals.

5
In re: ........................................................................................................................ 6
.........................................................................................................
NAME OF CHILD DATE OF BIRTH

7
.................................................................................................................................... 8
.........................................................................................................
NAME OF FATHER NAME OF MOTHER
Present:
[ ] Child ........................................................................................................ [ ] Attorney for child .............................................................................
[ ] Father ...................................................................................................... [ ] Mother ..................................................................................................
[ ] Guardian or legal custodian ............................................................. [ ] Person standing in loco parentis .................................................
9 [ ] Agency representative ....................................................................... [ ] Attorney for agency .........................................................................
[ ] Court Services Unit representative ............................................... [ ] Attorney for Commonwealth ........................................................
[ ] Other ........................................................................................................ [ ] Other .....................................................................................................
A hearing has been held to dispose of a petition filed pursuant to Virginia Code § 16.1-241. All provisions of the Juvenile
and Domestic Relations District Court law have been duly complied with in assuming jurisdiction over the child and all
relevant and material evidence has been considered.
HAVING CONSIDERED ALL RELEVANT AND MATERIAL EVIDENCE PRESENTED AND THE BEST INTEREST OF
THE CHILD, THE COURT FINDS THAT THE CHILD IS WITHIN THE JURISDICTION OF THIS COURT AND
FURTHER FINDS THAT:
A. Proper notice of this hearing was provided by the court to the:
[ ] child [ ] mother
[ ] father [ ] person standing in loco parentis
10 [ ] guardian or legal custodian [ ] other ........................................................................................................................
[ ] agency [ ] other ........................................................................................................................
[ ] Court Services Unit

B. [ ] Continued placement in the home would be contrary to the welfare of the child, based upon:
[ ] the facts contained in the following document(s) filed in this case, which is (are) incorporated by reference:
.............................................................................................................................................................................................................................................
11 .............................................................................................................................................................................................................................................

[ ] the following facts: 12

..................................................................................................................................................................................................

[ ] the following facts: 14

..................................................................................................................................................................................................

FORM DC-562 (MASTER, PAGE ONE OF TWO) 07/05

Form DC-562 ORDER FOR CONTINUED CUSTODY Form DC-562
TRANSFER TO AGENCY

Data Elements, page one

1. Insert court case number.

2. Insert the date of the hearing at which this order is entered.

3. Insert the county or city of the court in which this order is entered.

4. Check the applicable box.

5. Insert the name of the child who is the subject of the petition.

6. Insert the child’s date of birth.

7. Insert the father’s name.

8. Insert the mother’s name.

9. Check the boxes to indicate who is present at the hearing, and insert the names of those
persons who are present.

10. Check the boxes to indicate who received notice of the hearing.

11. Check the applicable boxes.

12. Specify on the lines provided the document(s) that contain facts that substantiate that
continued placement in the home would be contrary to the welfare of the child and/or
other facts that substantiate the Court’s finding.

13. Check the applicable boxes

14. Specify on the lines provided the document(s) that contain facts that substantiate the
Court’s finding on reasonable efforts to prevent removal of the child from home and/or
other facts that substantiate this finding.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
1
Case No. ......................................................................................

THE COURT ORDERS THE FOLLOWING:

C. [ ] TEMPORARY PLACEMENT –
The above-named child shall temporarily be placed with the local board of social services of
2 ......................................................................................................... without prior notice or an opportunity to be heard because:
CITY/COUNTY

1. [ ] the following emergency and need for temporary placement exists:

3 .....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................

4 [ ] the local board of social services consents to the commitment of the child’s custody to the board.
OR
5 D. [ ] TRANSFER OF LEGAL CUSTODY –
Legal custody of the child is transferred to ....................................................................................................................................... , which:
PUBLIC OR PRIVATE CHILD-PLACING AGENCY
1. [ ] was provided with prior notice and an opportunity to be heard.
6 2. [ ] consents to the commitment of the child’s custody.
E. Relocation. Each party intending a change of address shall give 30 days advance written notice of such change of
address to the court and other party, pursuant to Virginia Code § 20-124.5. Unless otherwise provided in this order,
this notice shall contain the child’s full name, the case number of this case, the party’s new telephone number and new
street address, and if different, the party’s new mailing address. Unless otherwise provided in this order, the notice
shall be mailed by first-class or delivered to this court and to the other party.
F. Access to Records. In accordance with Virginia Code § 20-124.6, neither parent, regardless of whether such parent
has custody, shall be denied access to the academic or health records of that parent’s minor child, unless otherwise
provided in this order or, in the case of health records, if the minor’s treating physician or clinical psychologist has
made a part of the child’s health record a written statement that furnishing to or review by the parent of such health
records would be reasonably likely to cause substantial harm to the minor or another person.
G. [ ] As this order requires the local board of social services to temporarily accept the child for placement . without
prior notice or an opportunity to be heard, a hearing shall be held within 14 days on
7
.......................................................................................................................... at ......................................................................................... .
DATE TIME

H. A hearing to review the foster care plan pursuant to Virginia Code § 16.1-281 shall be held within 60 days of the
earlier of the temporary placement of the child with the local board of social services pursuant to paragraph C. above,
or the transfer of legal custody of the child to the local board or agency pursuant to paragraph D. above.
This hearing shall be held on 8
......................................................................................................... at .................................................... .
DATE TIME

8
and the local board or agency shall file the foster care plan by .............................................................................................. .
DATE
The local board or agency shall promptly file with the Court district court form DC-620, AFFIDAVIT (UNIFORM CHILD
CUSTODY JURISDICTION AND ENFORCEMENT ACT), and the parents shall cooperate with the local board or agency to
provide any necessary information.
I. The clerk shall complete an Order for Appointment of Guardian Ad Litem to represent the child who has been placed
in foster care and other order(s) for appointment of counsel or guardian ad litem as directed by the Court.
J. [ ] Other: .......................................................................................................................................................................................................................................
9 ......................................................................................................................................................................................................................................................

10
....................................................................................... 11
_____________________________________________________________
DATE JUDGE

FORM DC-562 (MASTER, PAGE TWO OF TWO) 07/14

Form DC-562 ORDER FOR CONTINUED CUSTODY Form DC-562
TRANSFER TO AGENCY

Data Elements, page two

1. Insert the court case number.

2. If applicable, check the box and insert the name of the local department of social services
with whom the child is being placed.

3. If applicable, check the box and describe the emergency and need for temporarily placing
the child with the local department of social services.

4. Check the box, if applicable.

5. If applicable, check the box and insert the name of the local department of social services
to whom legal custody of the child is transferred.

6. Check the applicable box(es).

7. If applicable, check the box and insert the date and time for a hearing on the child's
temporary placement with the local department of social services.

8. Since the local department of social services has been given temporary placement
responsibility or legal custody of the child by this order, insert the date and time for a
hearing on the foster care plan, and the date by which the agency shall file the foster care
plan.

9. Check the box and specify any other orders of the court on the lines provided, as
appropriate.

10. Insert the date on which the order is signed.

11. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
Form DC-564 PETITION FOR RESTORATION OF Form DC-564
PARENTAL RIGHTS

Using This Form

1. Copies

a. Original – Filed with the court.

2. Prepared by the petitioner. Pursuant to Va. Code § 16.1-283.2, the petitioner is either the
local board of social services or the child’s guardian ad litem, or both.

3. Preparation details – a separate petition must be filed for each former parent for whom
the restoration of parental rights is being requested.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2013
PETITION FOR RESTORATION OF 1
Court Case No. .........................................................................
PARENTAL RIGHTS
Commonwealth of Virginia Va. Code § 16.1-283.2 2
Agency Case No. .....................................................................

USING THIS FORM

• This form is to be used to request the restoration of a former parent’s rights: [ ] Mother [ ] Father
• Indicate the former parent whose rights are the subject of the petition by checking the appropriate box above. A separate
petition must be filed for each former parent whose rights are the subject of a petition for restoration of parental rights.

[ ] Male
4 4 [ ] Female
In re: ...............................................................................................................................................................
NAME OF CHILD

Petitioner(s):
7
[ ] ............................................................................................................. 8
[ ] ..................................................................................................................
LOCAL DEPARTMENT OF SOCIAL SERVICES GUARDIAN AD LITEM

9
...................................................................................................................... 10
...........................................................................................................................
FORMER PARENT WHOSE RIGHTS ARE THE SUBJECT OF THIS PETITION PARENT WHO RETAINS LEGAL RIGHTS TO THE CHILD

11 [ 11
] A Court-Appointed Special Advocate has been appointed for the child: ...................................................................................................................
NAME OF CHILD’S COURT-APPOINTED SPECIAL ADVOCATE

I, the undersigned Petitioner, state under oath to the best of my knowledge and belief that the following are true:
1. 12
The above-named child is in the custody of the .................................................................................................... and a pre-adoptive parent
LOCAL DEPARTMENT OF SOCIAL SERVICES
or parents have not been identified and approved for the child.
2. [ ] The child is at least 14 years of age and consents to the restoration of parental rights.
OR
[ ] The child is younger than 14 years of age and
13 [ ] is the sibling of a child for whom a petition for restoration of parental rights has been filed.
OR
[ ] the child’s guardian ad litem and the ....................................................................................................... are filing the petition jointly.
LOCAL BOARD OF SOCIAL SERVICES

3. 14
The rights of the child’s parent were terminated by ............................................................................................ Court under a final order
14
pursuant to subsection B, C, or D of § 16.1-283 on ............................... .
DATE
[ ] This date is at least two years prior to the filing of the petition to restore parental rights.
15 OR
[ ] The child will turn 18 before the expiration of the two-year period following termination of parental rights.
4. The child was previously adjudicated to be
[ ] an abused or neglected child. [ ] a child in need of supervision.
16 [ ] a child in need of services. [ ] a delinquent child.
5. 17
The permanency goal for the child of ....................................................... [ ] has not been achieved [ ] was achieved but not sustained.
PERMANENT GOAL
AND
6. The parent whose rights are to be reinstated consents to the restoration of parental rights.

FORM DC-564 (MASTER, PAGE ONE OF TWO) 07/13

Form DC-564 PETITION FOR RESTORATION OF Form DC-564
PARENTAL RIGHTS

Data Elements, page one

1. Insert court case number.

2. Insert child-placing agency case number.

3. Insert name of court.

4. Insert name of child who is the subject of the case, and check box indicating gender of
child.

5. Insert age (in years and months) of child named in Data Element No. 4.

6. Insert date of birth of child named in Data Element No. 4.

7. If the local department of social services is the petitioner in this case, check this box and
insert name and address.

8. If a guardian ad litem is the petitioner in this case, check this box and insert name and
address.

9. Insert name and address of former parent whose rights are the subject of this petition.

10. Insert name and address of parent who retains legal rights to the child.

11. Check this box, if applicable, and insert name of child’s court-appointed special
advocate.

12. Insert name of local department of social services which has custody of the child.

13. Check the applicable box and insert the appropriate information.

14. Insert name of court which terminated the rights of the child’s parent and date of order
terminating those rights.

15. Check applicable box.

16. Check applicable box reflecting adjudication of child.

17. Insert the permanent goal for the child, and check applicable box to indicate whether or
not that permanent goal has been achieved.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2013
1
Court Case No. .........................................................................

Wherefore, Petitioner requests that the Court grant the following relief and such other relief as the child’s best interest
requires:

1. Docket the case for a hearing to be held not less than 60 days after the filing of this petition.
2. Serve notice of the hearing and a copy of this petition pursuant to Virginia Code §§ 16.1-263 and 16.1-283.2, to the following:
• Child, if he/she is 12 years of age or older.
• Former parent of the child whose rights are the subject of this petition.
• Any other parent who retains legal rights to the child.
• Child’s Court-Appointed Special Advocate, if one has been appointed.
• Child’s guardian ad litem, if not the petitioner.
• Local board of social services, if not the petitioner.

3. Enter an order incorporating the placement plan to be developed for the child by the local board of social services pursuant to
§ 16.1-283.2(E), and permitting the local board of social services to place the child with the former parent whose rights are the
subject of this petition, subject to the visitation required pursuant to § 16.1-283.2(F).

4. Enter an order restoring the rights of the child’s former parent whose rights are the subject of this petition, upon consideration of
the report to be filed pursuant to §16.1-283.2(G).
2
..................................................................................................................
LOCAL BOARD OF SOCIAL SERVICES

3
....................................................................................... 4
_________________________________________________________
DATE PETITIONER, LOCAL BOARD OF SOCIAL SERVICES

5
Subscribed and sworn to before me this ..................................................... 6
_________________________________________________________
DATE [ ] INTAKE OFFICER [ ] CLERK

FOR NOTARY PUBLIC’S USE ONLY:

7
State of ........................................................................................................ 8
[ ] City [ ] County of .............................................................................

9
Acknowledged, subscribed and sworn to before me this ..................... day of ............................................................... , 20 ..........................

10
.............................................................................................. 11
_____________________________________________________________
NOTARY REGISTRATION NUMBER NOTARY PUBLIC
11
(My commission expires: ...........................................)

12
..................................................................................................................
NAME OF PETITIONER, GUARDIAN AD LITEM

13
....................................................................................... 14
_________________________________________________________
DATE PETITIONER, GUARDIAN AD LITEM

5
Subscribed and sworn to before me this ..................................................... 6
_________________________________________________________
DATE [ ] INTAKE OFFICER [ ] CLERK

FOR NOTARY PUBLIC’S USE ONLY:

9
Acknowledged, subscribed and sworn to before me this ..................... day of ............................................................... , 20 ..........................

FORM DC-564 (MASTER, PAGE TWO OF TWO) 07/13

Form DC-564 PETITION FOR RESTORATION OF Form DC-564
PARENTAL RIGHTS

Data Elements, page two

1. Insert court case number.

2. Print name of local board of social services, if applicable.

3. Date signed by person on behalf of agency named in Data Element No. 2.

4. Signature of petitioner (local board of social services).

5. Insert date on which signature of petitioner is verified.

6. Signature of officer verifying signature of petitioner. Check box to indicate title.

7. If acknowledgment taken by a notary public, insert state in which acknowledgment is

taken.

8. Locality in which acknowledgment is taken. Check the applicable box to indicate the
city or county.

9. Insert date of acknowledgment.

10. Insert notary public’s registration number.

11. Signature of notary public taking acknowledgment and expiration date of commission.

12. Print name of guardian ad litem, if applicable.

13. Date signed by person named in Data Element No. 12.

14. Signature of petitioner (guardian ad litem).

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2013
Form DC-565 NOTICE OF PRESENTATION Form DC-565
OF DRIVER'S LICENSE

Using This Form

1. Copies

a. Original – to driver.

2. Prepared by clerk.

3. Attachments – none.

4. Preparation details – These forms are pre-printed post cards, and may be overprinted if
2,000 or more are ordered.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
NOTICE OF PRESENTATION OF DRIVER’S LICENSE VA. CODE ANN § 46.2-336

The Department of Motor Vehicles has sent your Driver’s License to this Court
for presentation to you as required by law.

You are scheduled to appear with a parent or guardian*, in the

1
......................................................................................................................................................................

......................................................................................................................................................................

2
to receive your Driver’s License on .......................................................................................... m.

This is a courtroom proceeding and each licensee and parent must be appropriately
dressed. Please bring both your Driver Education Certificate (or Ninety-Day
Temporary Driver’s License) and your learner’s permit for collection by the court.
Persons who arrive LATE and/or inappropriately dressed will not be admitted, but
given a new date to appear.

* If you will be 18 or older on the date shown on this NOTICE, your parent or
guardian is not required to attend.
FORM DC-565 07/12
Form DC-565 NOTICE OF PRESENTATION Form DC-565
OF DRIVER'S LICENSE

Data Elements

1. Name and address of location where driver's license ceremony is to be held.

2. Date and time of presentation may be stamped on the card.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
Form DC-566 PARENTAL PLACEMENT ORDER FOR Form DC-566
RESTORATION OF PARENTAL RIGHTS

Using This Form

1. Copies

a. Original – to court.

b. Copies to parties to the case.

2. Prepared by judge.

3. Preparation details – order issued at the first hearing on the petition for restoration of
parental rights.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2013
PARENTAL PLACEMENT ORDER FOR 1
Case No. ...............................................................................................
RESTORATION OF PARENTAL RIGHTS
Commonwealth of Virginia Va. Code § 16.1-283.2 2
Agency Case No. ..............................................................................

3
..................................................................................................................
DATE OF HEARING

[ ] Circuit Court
4
........................................................................................................................... [ ] Juvenile and Domestic Relations District Court
5
In re: ............................................................................................................... 7
...........................................................................................................................
NAME OF CHILD NAME OF FORMER PARENT ([ ] FATHER [ ] MOTHER)

6
........................................................................................................................... 8
...........................................................................................................................
DATE OF BIRTH NAME OF PARENT’S ATTORNEY

Present: [ ] Mother ..................................................................................... [ ] Mother’s attorney ....................................................................................

[ ] Former Parent [ ] Retains legal rights
9 [ ] Father ....................................................................................... [ ] Father’s attorney ......................................................................................
[ ] Former Parent [ ] Retains legal rights
[ ] Child ......................................................................................... [ ] Guardian ad litem ....................................................................................
[ ] Agency Representative ...................................................... [ ] Agency Attorney ......................................................................................
[ ] Foster Parent(s) ..................................................................... [ ] CASA ...........................................................................................................

10
A PETITION FOR RESTORATION OF PARENTAL RIGHTS was filed on .......................................................................................
DATE
11
by ...................................................................................................................................... , Petitioner(s).

1. [ ] A hearing on the petition for restoration of parental rights has been held and notice of the hearing and a copy of the petition
filed pursuant to Va. Code § 16.1-283.2 was served by the court on the:
12 [ ] Mother, who retains legal rights [ ] Guardian ad litem for the child
[ ] Father, who retains legal rights [ ] Local Department of Social Services
[ ] Former Mother [ ] CASA ...............................................................................................................................
[ ] Former Father [ ] Other ................................................................................................................................
HAVING HEARD ALL THE EVIDENCE, THE COURT FINDS THAT THE CHILD IS WITHIN THE JURISDICTION OF
THIS COURT, AND FINDS AS FOLLOWS:
2. The circumstances required pursuant to Va. Code § 16.1-283.2 A (1-4) to file a petition to restore the previously terminated
parental rights of the child’s parent as alleged in the petition
[ ] have been met.
13 [ ] have not been met, and the petition is dismissed.
3. [ ] As the child [ ] is younger than 14 years of age [ ] will turn 18 before the expiration of the two-year period following
14 termination of parental rights, the petition is
[ ] accepted as being in the best interest of the child
[ ] not accepted as being in the best interest of the child, and the petition is dismissed. Custody remains with the
.............................................................................................................................................................................................................................................
LOCAL DEPARTMENT OF SOCIAL SERVICES

4. [ ] The child, who is at least 14 years of age

15 [ ] consents to the restoration of parental rights.
[ ] does not consent to the restoration of parental rights, and the petition is dismissed.
[ ] The former parent whose rights are the subject of this petition
[ ] consents to the restoration of parental rights.
[ ] does not consent to the restoration of parental rights, and the petition is dismissed.

FORM DC-566 (MASTER, PAGE ONE OF TWO) 07/13

Form DC-566 PARENTAL PLACEMENT ORDER FOR Form DC-566
RESTORATION OF PARENTAL RIGHTS

Data Elements, page one

1. Insert court case number.

2. Insert child-placing agency case number.

3. Insert date of hearing at which this order is entered.

4. Insert name of court and check appropriate box.

5. Insert name of child who is subject of case.

6. Insert date of birth of child named in Data Element No. 5.

7. Insert name of former parent whose rights are the subject of this order. Check box to
indicate mother or father.

8. Insert name of attorney of parent named in Data Element No. 7.

9. Check boxes to indicate the persons present at the hearing and insert the names of those
present.

10. Insert date on which the petition for restoration of parental rights was filed.

11. Insert name of petitioner(s).

12. Check appropriate boxes to indicate who was served with notice of the hearing and a
copy of the petition.

13. Check the appropriate box to indicate whether or not the required circumstances in order
to file a petition have been met.

14. If one of the indicated situations exist with respect to the age of the child, check the
appropriate boxes, and then check the applicable box indicating whether or not the
petition is accepted.

15. Check the applicable boxes indicating if child and the former parent consent to the
restoration of parental rights.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2013
1
Case No. ...............................................................................................

2 5. [ ] A written placement plan was developed by the local department of social services pursuant to Va. Code § 16.1-283.2 E and
filed with the Court on ............................................................................
DATE
The placement plan, which meets the requirements of Va. Code § 16.1-283.2 E, is
[ ] approved and incorporated by reference.
3 [ ] approved with the following revisions, and, as revised, is incorporated by reference.
.............................................................................................................................................................................................................................................

shall be held on ...................................................................................

DATE AND TIME

OR
5 [ ] The placement plan is disapproved and the petition is dismissed.

6
....................................................................................... 7
______________________________________________________________________
DATE JUDGE

FORM DC-566 (MASTER, PAGE TWO OF TWO) 07/13

Form DC-566 PARENTAL PLACEMENT ORDER FOR Form DC-566
RESTORATION OF PARENTAL RIGHTS

Data Elements, page two

1. Insert court case number.

2. Check this box if the written placement plan was developed by the local department of
social services and insert the date on which it was filed with the court.

3. Check the applicable box, and insert any revisions to the placement plan, if appropriate.

4. Check the applicable boxes, and insert the required information.

5. Check this box if the placement plan is not approved and the petition is dismissed.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2013
Form DC-567 ORDER FOR RESTORATION OF Form DC-567
PARENTAL RIGHTS

Using This Form

1. Copies

a. Original – to court.

b. Copies to parties to the case.

2. Prepared by judge.

3. Preparation details – order issued at final hearing on the petition for restoration of
parental rights.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2013
ORDER FOR RESTORATION OF 1
Case No. ...............................................................................................
PARENTAL RIGHTS
Commonwealth of Virginia Va. Code § 16.1-283.2 2
Agency Case No. ..............................................................................
3
..................................................................................................................
DATE OF HEARING

4
......................................................................................................... [ ] Juvenile and Domestic Relations District Court [ ] Circuit Court
5
In re: ............................................................................................................... 7
.........................................................................................................
NAME OF CHILD NAME OF FORMER PARENT ([ ] FATHER [ ] MOTHER)

Present: [ ] Mother .......................................................................................... [ ] Mother’s attorney .................................................................................

[ ] Former parent [ ] Retains legal rights
[ ] Father ............................................................................................ [ ] Father’s attorney ...................................................................................
9 [ ] Former parent [ ] Retains legal rights
[ ] Child .............................................................................................. [ ] Guardian ad litem .................................................................................
[ ] Agency Representative ........................................................... [ ] Agency Attorney ..................................................................................
[ ] Foster Parent(s) .......................................................................... [ ] CASA ....................................................................................................

10
A PETITION FOR RESTORATION OF PARENTAL RIGHTS was filed on ....................................................................................... .
DATE

1. [ ] A hearing on the petition for restoration of parental rights has been held and notice of the hearing and a copy of the visitation
report filed pursuant to Va. Code § 16.1-283.2 G was served by the court on the:
11
[ ] Mother, who retains legal rights [ ] Guardian ad litem for the child
[ ] Father, who retains legal rights [ ] Local Department of Social Services
[ ] Former Mother [ ] CASA ...............................................................................................................................
[ ] Former Father [ ] Other ................................................................................................................................
OR
12 [ ] A hearing has been held upon the motion of the [ ] court [ ] guardian ad litem [ ] local department of social services,
to revoke the order permitting the placement of the child with the former parent.
HAVING HEARD ALL THE EVIDENCE, THE COURT FINDS THAT THE CHILD IS WITHIN THE JURISDICTION OF
THIS COURT AND FINDS AS FOLLOWS:
2. [ ] The local department of social services has completed the visitation as required by § 16.1-283.2 F. A written visitation
report was filed with the court pursuant to § 16.1-283.2 G on ....................................................... .
DATE
Based upon the visitation report, which is incorporated by reference, [ ] and the following facts: .......................................................
......................................................................................................................................................................................................................................................
and having considered the factors set forth in § 16.1-283.2 I, the Court finds, by clear and convincing evidence, that the
restoration of parental rights
[ ] is in the best interest of the child.
The parental rights of the above-referenced former parent are hereby ordered restored, and custody of the child is
transferred to the former parent, namely:
13 .............................................................................................................................................................................................................................................
NAME OF FORMER PARENT AND ADDRESS
OR
[ ] is not in the best interest of the child and the petition is dismissed. Custody remains with the
.............................................................................................................................................................................................................................................
LOCAL DEPARTMENT OF SOCIAL SERVICES

A foster care review hearing shall be held on .................................................................... at ......................................, and

DATE TIME

shall file a petition for a foster care review hearing by .............................................................................. .

DATE
FORM DC-567 (MASTER, PAGE ONE OF TWO) 07/13
Form DC-567 ORDER FOR RESTORATION OF Form DC-567
PARENTAL RIGHTS

Data Elements, page one

1. Insert court case number.

2. Insert child-placing agency case number.

3. Insert date of hearing at which this order is entered.

4. Insert name of court and check appropriate box.

5. Insert name of child who is subject of the case.

6. Insert date of birth of child named in Data Element No. 5.

7. Insert name of former parent whose rights are the subject of this order. Check box to
indicate mother or father.

8. Insert name of attorney of parent named in Data Element No. 7.

9. Check boxes to indicate the persons present at the hearing and insert the names of those
present.

10. Insert date on which the petition for restoration of parental rights was filed.

11. Check this box if a hearing was held on the petition for restoration of parental rights, and
check appropriate boxes to indicate who was served with notice of the hearing and a copy
of the visitation report.

12. Check this box if a hearing was held on a motion to revoke the parental placement order,
and check the appropriate box to indicate on whose motion the hearing was held.

13. Check the applicable boxes, and insert the required information as appropriate.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2013
1
Court Case No. ..................................................................................

2 3. [ ] For good cause shown, the order entered on ............................................ permitting placement of the child with the former parent
DATE
whose rights are the subject of the petition is revoked and the petition is dismissed. Custody of the child remains with the
......................................................................................................................................................................................................................................................
LOCAL DEPARTMENT OF SOCIAL SERVICES

A foster care review hearing shall be held on ............................................................................. at ......................................, and

DATE TIME

shall file a petition for a foster care review hearing by ....................................................................................... .

DATE

3 4. [ ] This order having been entered in the .................................................................................... Circuit Court, this matter is referred
CITY OR COUNTY

pursuant to Virginia Code § 16.1-297 to the ........................................................................................ Juvenile and Domestic Relations
CITY OR COUNTY
District Court for future proceedings.

4
....................................................................................... 5
______________________________________________________________________
DATE JUDGE

FORM DC-567 (MASTER, PAGE TWO OF TWO) 07/13

Form DC-567 ORDER FOR RESTORATION OF Form DC-567
PARENTAL RIGHTS

Data Elements, page two

1. Insert court case number.

2. Check this box if the parental placement order is revoked, and insert the relevant
information.

3. For use by a circuit court referring the case back to the juvenile and domestic relations
district court.

4. Date order signed by judge.

5. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2013
Form DC-568 JUVENILE COMMITMENT Page: 1
REVIEW HEARING ORDER

Using This Form

1. Copies

a. Original – to court.

b. First copy – to institution or agency to which juvenile is committed, if applicable.

c. Second copy – to juvenile.

d. Additional copies as determined by local practice.

2. Prepared by clerk, signed by judge.

3. Attachments

a. Form DC-569, DISPOSITION ORDER – DELINQUENCY

b. Form DC-572, JUVENILE COMMITMENT ORDER

c. Any supplemental form or court order with conditions related to probation or suspension
of commitment.

4. Preparation details –

This form would be used in following an order for commitment review as provided in district
court form DC-572, JUVENILE COMMITMENT ORDER, Data Element No. 17.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-568 JUVENILE COMMITMENT REVIEW HEARING ORDER Page: 2

JUVENILE COMMITMENT REVIEW HEARING ORDER

1
Case No. ..........................................................................
Commonwealth of Virginia VA. CODE §§ 16.1-272, -285, -285.1, -285 2, -289

[ ] Juvenile and Domestic Relations District Court

2
....................................................................................................................................... [ ] Circuit Court
3
................................................................................................................................................................... 4
...........................................................................
NAME OF JUVENILE (LAST, FIRST, MIDDLE) DATE OF COMMITMENT

5
..........................................................................................
6
....................................................................................................................................................
CURRENT CHARGE AND CODE SECTION UNDERLYING ELIGIBLE CHARGE FOR COMMITMENT AND CODE SECTION

The above-named juvenile is under the continuing jurisdiction of this court and proper notice to all parties
has been given in accordance with law for a hearing to review the juvenile commitment order. All progress reports,
evaluations and relevant evidence concerning the juvenile having been considered, the court ORDERS that:

7[ ] the purpose of the order of confinement having been achieved, the juvenile is released on probation for
a period of ............................................................... under [ ] the following conditions [ ] the attached conditions.
8 [ ] as the juvenile is consistently failing to comply with the conditions specified in by the court or the
policies and program requirements of the facility, the juvenile is committed to the Department of
Juvenile Justice on the attached order, which is incorporated by reference.
9 [ ] as the juvenile is not actively involved in any community facility based treatment program through no
fault of his own, the juvenile is released under [ ] the following conditions [ ] the attached conditions
of the suspended commitment.
10 [ ] continued commitment of the juvenile to the Department of Juvenile Justice if ordered for
[ ] completion of the original determinate period of commitment [ ] ...........................................................................
11 [ ] the juvenile shall serve the adult sentence imposed by prior order as follows ............................................................
12 [ ] the adult sentence is suspended as follows .......................................................................................................................................

14
......................................... ... ............................................ 15
_______________________________________________________________
DATE JUDGE

FORM DC-568 MASTER 11/06

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-568 JUVENILE COMMITMENT Page: 3
REVIEW HEARING ORDER

Data Elements

1. Court case number.

2. Name of court. Check appropriate box for type of court.

3. Juvenile’s name.

4. Date of juvenile’s commitment.

5. Insert statutory references and short description of current charge.

6. If appropriate, insert short description of underlying charge which relates to juvenile’s

eligibility for commitment and statutory reference.

7. Check box if juvenile is placed on probation. Insert appropriate amount of time and check
appropriate box for incorporated or attached conditions.

8. Check box if juvenile is committed to the Department of Juvenile Justice and a related order
is attached (e.g., form DC-572, JUVENILE COMMITMENT ORDER).

9. Check box if juvenile is released as part of a suspended commitment. Check appropriate box
for incorporated or attached conditions.

10. Check box if juvenile’s previously ordered commitment is continued. Check appropriate box
if commitment is for duration of previously entered, determinate period of time or for another
period of time.

11. Check box if juvenile must serve adult sentence imposed by prior order and fill blank with
appropriate amount of time and relevant terms.

12. Check box if adult sentence execution is suspended and fill blank with the appropriate
amount of time and relevant terms.

13. Check box for other disposition and fill blank with description of such disposition.

14. Date of entry of order.

15. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-569 DISPOSITION ORDER – DELINQUENCY Form DC-569

Using This Form

1. Copies

a. Original – to court.

b. First copy – to institution or agency if juvenile committed or enrolled.

c. Second copy – to juvenile.

d. Additional copies as determined by local practice.

2. Prepared by clerk, signed by judge.

3. Attachments

a. Form DC-572, JUVENILE COMMITMENT ORDER (may be referenced in Data

Element No. 11 on page 2 of form).

b. Form DC-577, DRIVER’S LICENSE SUSPENSION ORDER AND ENTRY INTO SERVICES
PROGRAM (JUVENILE) (may be referenced in Data Element Nos. 6 and 7 on page 2
of form).

4. Preparation details

This form may be used in hard copy or as a template to tailor to local needs. In light of
the local nature of many dispositions in delinquency cases, the form provides only a
sampling of common dispositions.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2010
DISPOSITION ORDER – Case No. 1
........................................................................................
DELINQUENCY Commonwealth of Virginia
2
............................................................................................................
HEARING DATE AND TIME
3
..................................................................................................................................................................................... Juvenile and Domestic Relations District Court

4
......................................................................................................................... In re/v. .....................................................................................................................
CHILD
Present:
[ ] Child ....................................................................................................... [ ] Attorney for child ..................................................................................
[ ] Father ...................................................................................................... [ ] Mother .......................................................................................................

[ ] Guardian or legal custodian ........................................................... [ ] Person standing in loco parents ......................................................

5 [ ] Agency representative ...................................................................... [ ] Attorney for agency .............................................................................

[ ] Court Services Unit representative .............................................. [ ] Attorney for Commonwealth ...........................................................

[ ] Other ....................................................................................................... [ ] Other ...........................................................................................................

Charge(s) Code Section(s) Court Case Number(s)

§
§
6 §
§
§
§

PLEA: 7
...................................................................................................................................................................................................................................................................

FINDINGS OF THE COURT: 8

UPON EVIDENCE PRESENTED, including all required reports filed in this matter, the Court ORDERS the following disposition for
the juvenile’s supervision, care and rehabilitation:
I. ACCOUNTABILITY FOR OFFENSES
9[ ] The Juvenile shall write [ ] an APOLOGY to the victim [ ] an ESSAY on ...............................................................................................................

10 [ ] The Juvenile shall pay RESTITUTION in the amount of $ ............................................................ accruing at the legal rate of interest from
the date [ ] ................................................................................................. of .............................................................. to the Clerk’s office for the benefit
of ........................................................................................................................................... within ........................ days ........................ months.
11 [ ] Restitution is ordered JOINTLY and SEVERALLY with ............................................................................................................................................
12 [ ] ..................................................................................................................................................................................................................................................................
13 [ ] The Juvenile shall [ ] enter into a payment agreement with the Court within ......................... days [ ] comply with the following
payment plan:
.........................................................................................................................................................................................................................................................................

II. DEFERRED OR SUSPENDED DISPOSITION

14 [ ] Pursuant to § 16.1-278.8(4), the Court DEFERS disposition to ..........................................................................................................................................
after which time the charge may be dismissed if said child exhibits good behavior and complies with the terms of this Order during
the period in which disposition is deferred.
15 [ ] The juvenile’s imposition of disposition is suspended for ................... months .................. years on condition that said child exhibits
good behavior and complies with the terms of this Order during the period in which disposition is suspended.

16 [ ] .........................................................................................................................................................................................................................................................................

FORM DC-569 (MASTER, PAGE ONE OF THREE) 05/08

Form DC-569 DISPOSITION ORDER – DELINQUENCY Form DC-569

Data Elements, page one

1. Court case number.

2. Hearing date and time.

3. Court name.

4. Style of case.

5. Check appropriate boxes and provide names of persons present for the hearing.

6. Insert offense(s), related statutory references and court case numbers in the columns
provided.

7. Insert plea.

8. Insert any findings of court.

9. Check appropriate box if juvenile required to write apology, essay on one or more topics,
or other similar written reparation. Space is provided for submission deadline.

10. Check the box and insert terms of restitution ordered by the court. Insert date from which
interest on restitution shall accrue and indicate if date of loss or disposition date.

11. Check the box if restitution is ordered jointly and severally and identify such additional
persons from whom restitution is required.

12. Check the box and insert any terms related to restitution.

13. Check the box if juvenile enters in an installment payment plan, deferred payment plan,
community service in lieu of payment or other payment plan and insert related terms in
the space provided.

14. Check the box if disposition deferred and provide for the related period of deferral in the
space allotted.

15. Check the box if final disposition is suspended and insert the related period of suspension
in the space allotted.

16. Check the box and insert any terms related to deferral or suspension of disposition.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2010
Case No. 1
.............................................................................................
III. GENERAL CONDITIONS
[ ] The juvenile shall be of GOOD BEHAVIOR, and follow HOUSE and SCHOOL RULES, which include compliance with
COMPULSORY SCHOOL ATTENDANCE unless otherwise noted.
[ ] The juvenile shall observe CURFEW as follows: .................................................................................... [ ] and [ ] or have NO CONTACT
[ ] as follows: .........................................................................................................................................................................................................................................

with [ ] co-defendant(s) [ ] victim(s) [ ] victim’s family

[ ] The juvenile shall not go on the premises of ............................................................... [ ] the victim [ ] .......................................................................
[ ] The juvenile and parent/legal guardian shall cooperate with Court Services Unit (CSU) and all professional providers.
[ ] .........................................................................................................................................................................................................................................................................

IV. SPECIAL CONDITIONS

[ ] The juvenile shall be excused from COMPULSORY SCHOOL ATTENDANCE.
3 [ ] .........................................................................................................................................................................................................................................................................

V. FINES, PENALTIES AND LICENSURE

4 [ ] The juvenile shall pay a FINE of $ ................................................................ (not to exceed $500).
5 [ ] The juvenile shall pay a CIVIL PENALTY of $ ..........................................................................
6 [ ] The juvenile’s DRIVER’S LICENSE (or ability to obtain a driver’s license) shall be suspended for ................................................................
7 [ ] The juvenile shall be issued a restricted driver’s license (see specific restriction on restricted license form).
VI. REHABILITATIVE/EDUCATIONAL
[ ] The juvenile shall enter into and comply with REHABILITATIVE or EDUCATIONAL SERVICES and PROGRAMS as directed
by the CSU.
[ ] The juvenile shall take a TOUR of a detention center upon a schedule set by the P.O.
8 [ ] The juvenile shall enroll in, attend and complete the following REHABILITATIVE SERVICES until released by the counselor:
[ ] Substance abuse evaluation and recommended treatment [ ] Anger control counseling
[ ] Family counseling [ ] Individual counseling [ ] Sex offender
9[ ] .........................................................................................................................................................................................................................................................................

VII. COMMUNITY DISPOSITION

[ ] The juvenile shall perform ............ hours of COMMUNITY SERVICE, as directed by [ ] CSU [ ] ................................................................

within ..................... days ........................ months [ ] ................................................................................................................................................................... .

[ ] The juvenile is placed [ ] under HOUSE ARREST [ ] on ELECTRONIC MONITORING [ ] on OUTREACH DETENTION
10 [ ] ....................................................... for ...................... days ........................ with ................... day suspended on condition of compliance with
this order subject to the following terms and conditions: ......................................................................................................................................................
[ ] The juvenile is placed on UNSUPERVISED PROBATION under such conditions as prescribed by the Court.
[ ] The juvenile is place on SUPERVISED PROBATION through the CSU of this court for [ ] ..................... months [ ] indeterminate
amount of time. The juvenile and parent/legal guardian shall follow all rules of probation.

VIII. COMMITMENT
[ ] The juvenile is sentenced to the DETENTION HOME for ................. days with .................. days suspended on condition of compliance
with this Order.
11 [ ] The juvenile/defendant is sentenced to JAIL for .................... days ................. months.
[ ] The juvenile is committed as a SERIOUS OFFENDER to the DEPARTMENT OF JUVENILE JUSTICE for ................... years.
[ ] Indeterminate commitment [ ] ..................................................................................................................................................................................................... .
12 [ ] See attached order of [ ] determinate commitment [ ] ..................................................................................................................................................... .
FORM DC-569 (MASTER, PAGE TWO OF THREE) 11/10
Form DC-569 DISPOSITION ORDER – DELINQUENCY Form DC-569

Data Elements, page two

1. Court case number.

2. Check the applicable box(es) and provide details in the space allotted, e.g., name(s) and
addresses, if appropriate.

3. Check the box, if applicable, and insert any special conditions in the space provided.

4. Check the box if juvenile ordered to pay a fine and insert dollar amount in the space
provided.

5. Check the box if juvenile ordered to pay a civil penalty and insert dollar amount in the
space provided.

6. Check the box if juvenile’s driver’s license (or ability to obtain a driver’s license) is
suspended and insert related period in the space provided.

7. Check the box if juvenile will be issued a restricted driver’s license.

8. Check the applicable box(es).

9. Check the box and insert any terms related to rehabilitation or education of the juvenile.

10. Check the applicable box(es) and provide details in the space allotted.

11. Check the applicable box(es) and provide details in the space allotted.

12. Check the appropriate box if determinate or other commitment order is attached to
incorporate such order by reference.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2010
Case No. 1
.............................................................................................
IX. ADDITIONAL CONDITIONS

[ ] 2
.........................................................................................................................................................................................................................................................................

[ ] .........................................................................................................................................................................................................................................................................
3 [ ] Additional page(s) attached and incorporated.
4
[ ] This case is continued to ....................................................................................

5
............................................................. 6
______________________________________________________________________
DATE JUDGE

FORM DC-569 (MASTER, PAGE THREE OF THREE) 05/08

Form DC-569 DISPOSITION ORDER – DELINQUENCY Form DC-569

Data Elements, page three

1. Court case number.

2. Use the space provided for any additional terms and conditions.

3. Check the box to indicate that additional page(s) are attached and incorporated by
reference.

4. Check the box if case is continued to another date. Insert future hearing date.

5. Date of entry of order.

6. Judge’s signature.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2010
DC-570 ORDER DC-570

Using This Form

1. Copies

a. Original--to court.

2. Prepared by judge.

3. Attachments--none.

4. Preparation details

a. This form may be used as the order in the case, except for support order entry.
Its use is optional.

b. The reverse side should be used for additional notes, findings, etc.

DISTRICT COURT MANUAL FORMS VOLUME

Twenty-Third Edition, revised July 1999
DC-570 ORDER DC-570

Data Elements

1. Court name.

2. Style of the case.

3. Court case number.

4. Check parties to the case who are present and list other persons.

5. Check box for type of case. Use line if not covered by boxes.

6. Type of hearing.

7. Insert plea of juvenile, if applicable.

8. Insert findings of the court.

9. Insert orders of the court.

10. Insert date to which case is continued, if applicable.

11. Date of hearing.

12. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

Twenty-Third Edition, revised July 1999
Form DC-572 JUVENILE COMMITMENT ORDER Page: 1

Using This Form

1. Copies

a. Original – to court.

b. First copy – to institution or agency to which juvenile is committed.

c. Second copy – to juvenile.

d. Additional copies as determined by local practice.

2. Prepared by clerk, signed by judge.

3. Preparation details –

This form is to be used to commit a juvenile who has been found guilty of a delinquency
charge or willfully and materially violated a court or probation order to the Department of
Juvenile Justice, to a detention home or other secure facility or to a juvenile boot camp. For
other commitments (such as to a local board or public welfare or social service) or for change
in custody as a part of a disposition, use form DC-573, ORDER FOR CUSTODY/VISITATION
GRANTED TO INDIVIDUAL(S).

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-572 JUVENILE COMMITMENT ORDER Page: 2
JUVENILE COMMITMENT ORDER Current Case No. 1
.......................................................................
Commonwealth of Virginia VA CODE §§ 16 1-278 8, -284 1, -285, -285 1, 278 7, 290(A), Rule 8:17
[ ] Circuit Court
2
................................................................................................................................................ [ ] Juvenile and Domestic Relations District Court
In re 3
............................................................................................................................................................................................................................................. , a juvenile.
The above-named juvenile has been brought before this Court upon the filing of a written petition or warrant; and proper
notice has been given to all proper and necessary parties; the juvenile has been informed by this Court of their right to representation
by a lawyer, the right to a public hearing, the contents of the petition or warrant filed in this Court, and the right of the juvenile to
remain silent with regard to any allegation of delinquency, the right to confront and cross-examine witnesses, the right to present
evidence and the right to appeal a final decision of the court, and all provisions of the Juvenile and Domestic Relations District Court
Law, and amendments thereto, have been duly compiled with in assuming jurisdiction of the juvenile.
Having considered all relevant and material evidence, the Court finds that the juvenile is within the jurisdiction of this Court
and the Juvenile and Domestic Relations District Court Law and that the juvenile is guilty of the following delinquency charge:
4
............................................................................................................
CURRENT CHARGE FOUND DELINQUENT ON AND CODE SECTION
IF APPLICABLE, CHECK A BOX AND SKIP GRID:
5 [ ] FELONY [ ] VIOLATION OF PAROLE [ ] MISDEMEANOR (PRIOR FELONY) [ ] 4TH OR SUBSEQUENT MISDEMEANOR
IF CURRENT CHARGE IS VIOLATION OF PROBATION, COMPLETE THE FOLLOWING GRID:

Underlying Charge(s) Code Section(s) Court Case Number(s)

7 [ ] The court hereby ORDERS the juvenile to be committed to:

8 [ ] ................................................................................................................................................ for
DETENTION HOME OR SECURE FACILITY
.................................................................................
NOT TO EXCEED 6 MONTHS

9 [ ] as part of suspension of commitment to the Department of Juvenile Justice, with a review hearing to be held on
...................................................................................................
DATE AND TIME

10 [ ] with such commitment being suspended on further condition that the juvenile participate in the following community
treatment programs for the juvenile’s rehabilitation: ...................................................................................................................................................
.............................................................................................................................................................................................................................................................
11 [ ] the Department of Juvenile Justice for an indeterminate period.
12 [ ] the Department of Juvenile Justice [ ] for a period of ......................................................................... 13
[ ] until the juvenile’s twenty-first birthday.
14 [ ] ................................................................................................................................................ for .................................................................................
DETENTION HOME OR SECURE FACILITY NOT TO EXCEED 10 DAYS
for the willful and material violation of a court order issued or probation ordered pursuant to § 16.1-278.5. The court finds that
placement in a nonsecure facility will not meet the child’s needs, that all other treatment options in the community have been
exhausted and secure placement is necessary to meet the child’s service needs. The bases for these findings are
......................................................................................................................................................................................................................................................................
15[ ] see attached
.....................................................................................................................................................................................................................................
If committed to the Department of Juvenile Justice, the court service unit of this court shall maintain contact with the juvenile
during the juvenile’s commitment. If not previously completed, a social history report pursuant to Virginia Code § 16.1-273 must
be completed in 15 days.
16 [ ] Having considered the assessment and found that the juvenile is an appropriate candidate for juvenile boot camp, the Court
hereby ORDERS that disposition is deferred and the juvenile is ORDERED to attend a boot camp established pursuant to Virginia
Code § 66-13, and the juvenile is placed in the temporary custody of the Department of Juvenile Justice upon admission to the
boot camp. The court service unit shall provide supervision to the juvenile and his or her family during the residential and
aftercare components of the boot camp program.
17 [ ] A motion/petition for a review of commitment having been made, a commitment review hearing is scheduled for
.............................................................. . All available progress reports and evaluations completed on the juvenile since commitment,
DATE AND TIME
Including but not limited to psychological, educational and medical evaluations, shall be filed with the court by .................................. .
DATE
18
.......................................................................................... 19
_______________________________________________________________________
DATE JUDGE
FORM DC-572 MASTER 11/07

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-572 JUVENILE COMMITMENT ORDER Page: 3
Data Elements

1. Court case number.

2. Court name.

3. Juvenile’s name.

4. Insert statutory references and short description of charges of which the juvenile was found
guilty.

5. Check appropriate box, if applicable. If charge relates to violation of probation, proceed to Data
Element No. 6.

6. Insert underlying offense(s), related statutory references and court case numbers.

7. Check box to indicate that the juvenile is to be committed to a facility.

8. Check box, identify facility and specify time (if required).

9. If disposition is commitment to a detention home or secure facility as a part of suspension of

commitment to Department of Juvenile Justice, check box and indicate the date of the review
hearing.

10. Check box if disposition is commitment as part of a suspended commitment to the Department
of Juvenile Justice and indicate programs that juvenile will attend.

11. Check box if juvenile is committed for an indeterminate period.

12. Check box if juvenile is committed for a definite period of time.

13. Check appropriate box delineating period of commitment of juvenile. If for a period of weeks,
months, or years, fill in blank with the appropriate amount of time.

14. Check box, identify facility and specify time if the juvenile is being committed for willful and
material violation of a court or probation order. The time may not exceed 10 days.

15. Write in the bases for findings supporting the commitment of the juvenile under these
circumstances. If the bases do not fit in the blanks provided, check box and attach a separate
sheet.

16. Check box if disposition is deferred and juvenile is committed temporarily to attend boot camp.

17. Check box if commitment review hearing scheduled and insert date and time. If post-
commitment reports and evaluations concerning the child are requested pursuant to § 16.1-287,
insert the date such information should be filed with the court.

18. Date of entry of order.

19. Judge’s signature.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-573 CUSTODY/VISITATION ORDER Form DC-573

Using This Form

1. Copies

a. Original – to court.

b. First copy – to person(s) to whom custody of juvenile is awarded.

c. Second copy – to juvenile.

d. Additional copies as determined by local practice.

2. Prepared by clerk, signed by judge.

3. Attachments

Form DC-573-S, SUPPLEMENTAL SHEET TO ORDER FOR CUSTODY/VISITATION

GRANTED TO INDIVIDUALS(S).

4. Preparation details – This form is used to award custody of a juvenile to a person.

NOTE: In cases involving transfer of custody to an agency, use Form DC-562, ORDER
FOR CUSTODY TRANSFER TO AGENCY, in delinquency cases, use Form DC-572, JUVENILE
COMMITMENT ORDER, in cases involving the termination of parental rights, use form DC-
531, ORDER FOR INVOLUNTARY TERMINATION OF RESIDUAL PARENTAL RIGHTS or DC-
534, ORDER FOR VOLUNTARY TERMINATION OF RESIDUAL PARENTAL RIGHTS.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
ORDER FOR CUSTODY/VISITATION 1
Case No. .........................................................................................................
GRANTED TO INDIVIDUAL(S)
Commonwealth of Virginia VA. CODE §§ 16.1-278.15, 20-124.2 2
.........................................................................................................................
DATE OF HEARING

4
In re: .............................................................................................................................. 5
..................................................................................................... .
NAME OF CHILD DATE OF BIRTH

Present: [ ] Father ............................................................................................. [ ] Father’s attorney ................................................................................

[ ] Mother ............................................................................................ [ ] Mother’s attorney ..............................................................................
6 [ ] Child ................................................................................................ [ ] Guardian ad litem ..............................................................................
[ ] Other ................................................................................................. [ ] Attorney ................................................................................................
[ ] Other ................................................................................................ [ ] Attorney ...............................................................................................
The above-named child has been brought before this Court upon the filing of a written petition or motion concerning custody or
visitation or for which transfer of custody is a dispositional alternative. Legal notice has been given to all proper and necessary
parties. All provisions of the Juvenile and Domestic Relations District Court Law have been duly complied with in assuming
jurisdiction over the child, and all determinations have been made in accordance with the standards set forth in Virginia Code § 16.1-
278.4, § 16.1-278.5, § 16.1-278.6 or § 16.1-278.8 or § 16.1-278.15 and §§ 20-124.1 through 20-124.10.
HAVING CONSIDERED ALL RELEVANT AND MATERIAL EVIDENCE PRESENTED AND THE BEST INTEREST OF
THE CHILD, THE COURT FINDS THAT THE CHILD IS WITHIN THE JURISDICTION OF THIS COURT AND
FURTHER FINDS AND ORDERS THAT:
1. [ ] The parties are in agreement on the arrangement for the child’s custody and visitation:
[ ] as set forth in the agreement dated .............................................. which is incorporated by reference.
7 [ ] as set forth in the attached document .............................................................................., which is incorporated.
[ ] as set forth below.
2. 8
Custody/Visitation .......................................................................................................................................................................................................................
...............................................................................................................................................................................................................................................................
...............................................................................................................................................................................................................................................................
...............................................................................................................................................................................................................................................................
...............................................................................................................................................................................................................................................................
...............................................................................................................................................................................................................................................................
The basis for the decision determining custody or visitation has been communicated to the parties orally or in writing. Except in
cases of consent orders for custody and visitation, the findings regarding the relevant factors set forth in Virginia Code § 20-124.5
have been communicated to the parties.

9 3. [ ] A supplemental sheet with additional findings and/or orders is attached and incorporated.
4. Relocation. Each party intending a change of address shall give 30 days advance written notice of such change of address to the
court and other party, pursuant to Virginia Code § 20-124.5. Unless otherwise provided in this order, this notice shall contain the
child’s full name, the case number of this case, the party’s new telephone number and new street address and, if different, the
party’s new mailing address. Unless otherwise provided in this order, the notice shall be mailed by first-class or delivered to this
court and to the other party.
5. Access to Records. In accordance with Virginia Code § 20-124.6, neither parent, regardless of whether such parent has custody,
shall be denied access to the academic or health records of that parent’s minor child, unless otherwise provided in this order or, in
the case of health records, if the minor’s treating physician or clinical psychologist has made a part of the child’s health record a
written statement that furnishing to or review by the parent of such health records would be reasonably likely to cause substantial
harm to the minor or another person.

10 6. [ ] Deployed Military Parents and Guardians. In accordance with § 20-124.10, the nondeploying parent or guardian shall
reasonably accommodate the leave schedule of the deploying parent or guardian, (ii) the nondeploying parent shall facilitate
opportunities for telephonic and electronic mail contact between the deploying parent or guardian and the child during the
deployment period, and (iii) the deploying parent or guardian shall provide timely information regarding his leave schedule to the
nondeploying parent or guardian.

11 7. This Order is [ ] FINAL [ ] TEMPORARY and a final hearing on this matter will be held on
12 12
............................................................................................................................... at .............................................................. m.
DATE TIME

13
................................................................. 14
_______________________________________________________________________________
DATE JUDGE

FORM DC-573 (MASTER, PAGE ONE OF ____) 07/12

Form DC-573 CUSTODY/VISITATION ORDER Form DC-573

Data Elements

1. Court case number.

2. Date of hearing.

3. Court name.

4. Case caption (name of child).

5. Date of birth of child.

6. Check boxes to indicate the persons present at the hearing and insert the names of those
present.

7. Check the applicable box(es) to indicate if an agreement or other attached document is

incorporated by reference, or if the parties reached an agreement that is set forth in this
order.

8. Indicate details of the custody and/or visitation arrangements.

9. Check this box if a supplemental sheet has been produced that needs to be incorporated
into the order.

10. Check this box for deployed military parents and guardians, if applicable.

11. Check the appropriate box to indicate whether this order is final or temporary.

12. If the order is temporary, enter the date and time for the next hearing on the matter.

13. Date of order.

14. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
SUPPLEMENTAL SHEET TO 1
Case No. ......................................................................................
ORDER FOR CUSTODY/VISITATION
GRANTED TO INDIVIDUAL(S) 2
.........................................................................................................
DATE OF HEARING

In re: 3
............................................................................................ 4
.............................................................................................................
NAME OF CHILD DATE OF BIRTH

Having ordered in Paragraph 3 of the first page of this order the attachment and incorporation of
this supplemental sheet for additional findings and/or orders of this Court,

THE COURT FURTHER FINDS AND ORDERS THAT:

6
FORM DC-573-S (MASTER, PAGE _____ OF _____) 6/06
Form DC-573 CUSTODY/VISITATION ORDER Form DC-573

Data Elements, Supplemental Sheet

1. Case number.

2. Date of hearing.

3. Name of child who is subject of order.

4. Date of birth of child who is subject of order.

5. Detailed additional findings and orders.

6. Enter number of pages.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2012
Form DC-574 INFORMATION CONSIDERED IN Form DC-574
CHILD CUSTODY/VISITATION PROCEEDINGS

Using This Form

This form can be given to the Petitioner at the time of filing of the petition and served
with the Summons in a custody and/or visitation proceedings. This form advises the parties to a
custody and/or visitation proceeding of the information considered by the court at the hearing.

Lines have been inserted after each type of requested information to allow the parties to
insert the information to bring with them to the hearing. This form is to be used only as a
worksheet for the parties. It cannot be entered into evidence in the proceeding.

DISTRICT COURT MANUAL FORMS VOLUME

JANUARY 2013
INFORMATION CONSIDERED IN CHILD CUSTODY/VISITATION PROCEEDINGS
Commonwealth of Virginia VA. CODE §§ 16.1-278.15, 20-124.3

At a hearing to determine the custody or visitation of a child, information on the following factors is considered by the judge, if presented by the
parties.

1. The child’s age and physical and mental condition, with due consideration to the child’s changing developmental needs. ...................................
.....................................................................................................................................................................................................................................................................

2. The age and physical and mental condition of each parent. ......................................................................................................................................................
.....................................................................................................................................................................................................................................................................

3. The relationship existing between each parent and the child, with due consideration given to the positive involvement with the child’s life
and the ability to accurately assess and meet the emotional, intellectual and physical needs of the child.
.....................................................................................................................................................................................................................................................................

4. The needs of the child, with due consideration given to other important relationships of the child, including but not limited to siblings, peers
and extended family members. .........................................................................................................................................................................................................
.....................................................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................................................

5. The role which each parent has played and will play in the future, in the upbringing and care of the child. ..............................................................
.....................................................................................................................................................................................................................................................................

6. The propensity of each parent to actively support the child’s contact and relationship with the other parent, including whether a parent has
unreasonably denied the other parent access to or visitation with the child. ........................................................................................................................
.....................................................................................................................................................................................................................................................................

7. The relative willingness and demonstrated ability of each parent to maintain a close and continuing relationship with the child, and the
ability of each parent to cooperate in and resolve disputes regarding matters affecting the child. .................................................................................
.....................................................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................................................

8. The reasonable preference of the child, if the child is deemed by this court to be of reasonable intelligence, understanding, age and
experience to express such a preference. .......................................................................................................................................................................................
.....................................................................................................................................................................................................................................................................

9. Any history of “family abuse” as that term is defined in § 16.1-228, specifically any act involving violence, force, or threat that results in
bodily injury or places one in reasonable apprehension of death, sexual assault or bodily injury and that is committed by a person against
such person’s family or household member, or any history of sexual abuse. If the court finds a history of family abuse or sexual abuse, the
court may disregard information pertaining to factor 6.

10. Other: ......................................................................................................................................................................................................................................................

FORM DC-574 MASTER 10/12

Form DC-575 JUVENILE CASE APPEAL/ Form DC-575
TRANSFER TRANSMITTAL

Using This Form

1. Copies
a. Original – to circuit court.
b. First copy – to circuit court, then to juvenile & domestic relations district court.
c. Second copy – file copy.

2. Prepared and signed by clerk except for receipt section which is signed by the circuit
court clerk.

3. Attachments – items (originals, not copies) described in part B of the form. See Using
This Form, 4(d).

4. Preparation details
a. This form is to be prepared and sent with any juvenile case being transmitted from
the juvenile and domestic relations district court to the circuit court.
• The first copy is returned to the juvenile and domestic relations district
court after the acknowledgment of receipt is executed by the circuit court
clerk’s staff.
• The second copy is maintained until the first copy is returned from circuit
court, after which the second copy may be destroyed.
b. The purposes of this transmittal form are:
• To alert the circuit court clerk’s office that this case is required to be kept
confidential pursuant to § 16.1-307.
• To alert the circuit court clerks as to the type of case for proper docketing
and statistical reporting.
• To show what case documents and exhibits were transmitted from the
juvenile and domestic relations district court clerk’s office to the circuit
court clerk’s office.
• To document who accepted the appeal/transfer case documents and
exhibits in the circuit court clerk’s office, when they were accepted, and
that the signer acknowledges acceptance of the items listed on the
transmittal form.
c. Because a juvenile may be detained in a variety of facilities on a statewide basis,
the juvenile and domestic relations district court clerk should add the city or
county and telephone number of the facility if it is in a different locality from the
circuit court.
d. The clerks should make a copy of all documents in the case and the copies should
be filed in the juvenile and domestic relations district court while the originals are
at the circuit court.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
JUVENILE CASE APPEAL/TRANSFER TRANSMITTAL Case No. 1
..................................................................
CONFIDENTIAL MATERIALS See Va. Code §§ 16.1-302, 16.1-305, 16.1-307
2
Case Type: ..............................................................

3
........................................................................................................................... Juvenile and Domestic Relations District Court

......................................................................................................................
4 In re/v. ......................................................................................................................

A. CASE TYPE
[ ] JUVENILE CERTIFICATION (§ 16.1-269.1)
[ ] JUVENILE TRANSFER to Circuit Court (§ 16.1-269.1)
[ ] JUVENILE APPEAL:
[ ] Traffic Infraction / Misdemeanor / Other [ ] Dispositional Hearing (Child Dependency)
5 [ ] Delinquency Felony [ ] Foster Care Review
[ ] Delinquency Misdemeanor [ ] Permanency Planning Hearing
[ ] Custody / Visitation [ ] Termination of Parental Rights
[ ] Child in Need of Services [ ] Other: ..............................................................................................

[ ] Child in Need of Supervision

B. ACCOMPANYING CASE DOCUMENTS AND EXHIBITS

[ ] Case documents ( .......................................................... number of sheets)
6 [ ] Check for bond (if applicable) – check number ......................................

[ ] Exhibits (list specific items below):

C. JUVENILE STATUS
[ ] Admitted to bail
7 [ ] In jail / detention / shelter care at .....................................................................................................................................................................

NOTICE: This transmittal may include confidential case record requiring preservation consistent with the provisions of
Virginia Code § 16.1-307.

I certify that the above-described items from this juvenile and domestic relations district court accompany this form.

8
....................................................................................... 9
_____________________________________________________________
DATE [ ] CLERK [ ] DEPUTY CLERK

10
The above-described items have been received in the circuit court of ...................................................................................................................

11
....................................................................................... 12
_____________________________________________________________
DATE [ ] CLERK [ ] DEPUTY CLERK

Original – Circuit Court; Copy – Juvenile and Domestic Relations District Court

FORM DC-575 MASTER 07/14

Form DC-575 JUVENILE CASE APPEAL/ Form DC-575
TRANSFER TRANSMITTAL

Data Elements

1. Juvenile and domestic relations district court case number.

2. Case type.

3. Court name.

4. Case name. Use same style of case name as shown in case papers.

5. Check the appropriate box to indicate the case type.

6. Check the appropriate box(es) and complete the lines beside each checked box to indicate
what is being transmitted with this form.

7. Check the appropriate box to indicate whether the juvenile is or is not being detained. If
detained, insert the name and (if not a local facility) the location and telephone number of
the place where the juvenile is detained. See Using This Form, 4(c).

8. Date of preparation of this form.

9. Signature of person preparing this form. Check the appropriate box below the signature
line to indicate the title of the preparer.

10. Name of the circuit court to which the case is being transmitted.

11. Date of receipt in circuit court.

12. Signature of person accepting the case in the circuit court. Check the appropriate box
below the signature line.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
Form DC-576 DRIVER’S LICENSE DENIAL ORDER (JUVENILE)/ Form DC-576
DRIVER’S LICENSE SUSPENSION ORDER
(UNDERAGE ALCOHOL VIOLATIONS)

Using This Form

1. Copies

a. Original – to offender.

b. First copy – to court.

c. Second copy – to Division of Motor Vehicles.

d. Third copy – to Alcohol Rehabilitation Program.

2. Prepared by clerk, signed by judge and offender.

3. Attachments – none.

4. Preparation details

a. This order is for use with cases of driving while intoxicated or with certain alcohol-
related or drug-related matters pursuant to Virginia Code §§ 4.1-305, 4.1-306 or 16.1-
278.9 and in failure to comply with school attendance and meeting requirements under
§ 22.1-258. This is a three-page order. The second and third pages to be used with this
form is designated as Form DC-261, RESTRICTED LICENSE ORDER. If offender is ordered
into a program for a non-traffic offense pursuant to Virginia Code § 16.1-278.8(9), then
use Form DC-577, DRIVER'S LICENSE SUSPENSION ORDER AND ENTRY INTO SERVICES
PROGRAM (JUVENILE). Do not use Form DC-265, RESTRICTED DRIVER'S LICENSE AND
ENTRY INTO ALCOHOL REHABILITATION PROGRAM, for a juvenile unless deferred
finding is dissolved and juvenile is convicted.

b. The original of this 4-part set is printed on safety paper (like bank checks) to prevent
forgery and tampering. Do not try to make corrections as changes cannot be made on
safety paper. If an error is made, the entire form must be retyped.

c. This form must be used whenever offender enters an Alcohol Rehabilitation Program
pursuant to Virginia Code § 16.1-278.9 even if the issuance of a restricted license is not
ordered. VASAP and DMV will use this form to provide better record-keeping regarding
Program participants.

d. The offender should be required to surrender his copy of the pre-existing order (if the
pre-existing order permitted the issuance of a restricted driver's license) before giving an
amended order to the offender.

e. If this order is entered for a juvenile, do not prepare an abstract of conviction to

accompany a copy of the order being sent to the Division of Motor Vehicles. Also, do
not send the driver's license with the order--the court holds the license while the order is
in effect. However, if the juvenile later fails to complete the program and is convicted of
a motor vehicle offense, an abstract is completed and sent at that time together with the
driver's license if it is then suspended.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2011
Form DC-576 DRIVER’S LICENSE DENIAL ORDER (JUVENILE)/ Form DC-576
DRIVER’S LICENSE SUSPENSION ORDER
(UNDERAGE ALCOHOL VIOLATIONS)
f. The identification information in this form is found on all warrants and summonses,
including the Virginia Uniform Summons. It is used to identify the offender who is
driving solely on this order pending a reinstatement and return of his driver's license by
the court. Verify that the date of birth agrees with the birth date shown on the driver's
license.

g. The driver's license number is used by the Virginia Department of Motor Vehicles for
driver's license records updating. The arresting officer uses it for radio records checks
and matching the order to the driver's license.

If the juvenile does not have a driver's license, use the offender's social security number
followed by "(SSN)." This data requirement does not authorize the issuance of a
restricted license order if the juvenile does not otherwise have a valid driver's license at
the time of conviction.

h. Data Element No. 18, page 1 may be used to postpone the commencement of the
restricted driving privilege so that the juvenile has, as a learning experience, a short
period of time without being permitted to drive.

i. In setting the expiration date in Data Element No. 19 on page 1, the judge should
consider:

• The estimated successful completion date of Program participation.

• The effect of any mandatory or discretionary license suspension imposed in

this case which comes into effect when the order expires.

No action by the court is required to restore the regular driver’s license to a juvenile when
this order expires.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2011
DRIVER’S LICENSE DENIAL ORDER (JUVENILE) Case No: 1
...............................................................................
DRIVER’S LICENSE SUSPENSION ORDER
COMPLETE DATA BELOW IF KNOWN
(UNDERAGE ALCOHOL VIOLATIONS)
Commonwealth of Virginia Va. Code §§ 4.1-305, 4.1-306, 16.1-278.9, 18.2-271.1 RACE SEX BORN HT. WGT. EYES HAIR
MO. DAY YR. FT. IN.
[ ] Circuit Court
2 [ ] General District Court 5
............................................................................................... STATE
CITY/COUNTY D.L.#
[ ] Juvenile and Domestic 6
Relations District Court
3
...............................................................................................
OFFENDER’S NAME (LAST, FIRST, MIDDLE) [ ] Drugs* [ ] Original Order
4 8 9
...............................................................................................
ADDRESS
7
................................................................. [ ] Alcohol [ ] Amended Order
OFFENSE DATE

............................................................................................... (*NO restricted driver’s license as disposition for drug violation under § 16.1-278.9)
CITY STATE ZIP

1. [ ] (Juvenile) The Court [ ] has found facts which justify a finding that you are delinquent and this finding involves a violation described
in Va. Code § 16.1-278.9 or [ ] has found that you have failed to comply with school attendance and meeting requirements, as provided
10 in Va. Code § 22.1-258. Therefore, pursuant to Va. Code § 16.1-278.9 your driver’s license and privilege to drive is ORDERED denied for
11
a period of ...................................................................................................................... which period shall be counted from
12 [ ] the date of this order [ ] three months following your sixteenth birthday. 13
[ ] (Adult) The Court has found [ ] you guilty [ ] facts sufficient to find you guilty of violating [ ] Va. Code § 4.1-305 [ ] Va. Code
§ 4.1-306. Therefore, your driver’s license and privilege to drive is ORDERED suspended for a period of
.............................................................................................................................................................. , which shall be counted from the date of this order.
2. [ ] yes [ ] no You are ORDERED on the terms and conditions listed below, to enter this program:
14 15
.......................................................................................................................................................................................................................................................................
PROGRAM/AGENCY NAME AND ADDRESS FEE

3. [ ] The offender was represented by counsel. 16 [ ] The offender waived his or her right to counsel.
4. [ ] No restricted license privilege is granted by this ORDER.

17 [ ] A restricted license privilege is granted to the offender for the purposes enumerated on the second and third pages of this Order and
subject to the conditions below.
CONDITIONS OF RESTRICTED LICENSE: This ORDER is entered and the restricted license is to be issued upon the following
conditions:
(1) This privilege is subject to any other conditions, restrictions, suspensions or revocations imposed by any court of competent
jurisdiction or the Virginia Department of Motor Vehicles. If your license is suspended for other reasons, the privileges of this license
may be VOID and the Department of Motor Vehicles may refuse to issue you a restricted license.
(2) If ordered to enter a Program, you shall satisfactorily and timely comply with and successfully complete the Program’s requirements.
(3) You must carry ALL THREE PAGES of this Order, and any attachment, at all times while operating a motor vehicle until this restricted
license expires or is withdrawn. If you are an adult, you must carry a copy of this order together with the restricted license to be issued by the
Virginia Department of Motor Vehicles upon receipt of such restricted license or by your home state license if you are not a Virginia resident.
(4) 18
................................................................................................................. Commencement date of restricted license privilege. In addition, if you are an
adult, this privilege EXPIRES 60 DAYS from this date if this ORDER is not accompanied by a restricted license issued by the Virginia
Department of Motor Vehicles or by your home state license if you are not a Virginia resident. This privilege EXPIRES 15 DAYS from this
date unless proof of enrollment in the Program named above is endorsed on the back of page one of this ORDER.
(5) 19
................................................................................................................. Expiration date of this restricted license Order unless withdrawn or modified by
this Court. Upon expiration of this restricted license Order, issuance of a driver’s license shall be subject to other conditions, restrictions,
suspensions or revocations imposed by any Court of competent jurisdiction or the Virginia Department of Motor Vehicles.
(6) You shall immediately notify this Court, the Virginia Department of Motor Vehicles and the Program of any change in residential address; or
of any change to any of the information listed in items “a” through “m” on pages two and three of this Order.
20
[ ] Please see reverse side for other applicable conditions.

WARNING: Forging or altering this Order or possessing a forged or altered order is a separate criminal offense punishable by fines and
incarceration. Va. Code §§ 18.2-107, 18.2-168, 18.2-169. Driving outside of these restricted privileges constitutes a separate criminal offense.

NOTE: This is page one of a three-page order.

FORM DC-576 (FRONT, PAGE ONE OF THREE) 07/11

Form DC-576 DRIVER’S LICENSE DENIAL ORDER (JUVENILE)/ Form DC-576
DRIVER’S LICENSE SUSPENSION ORDER
(UNDERAGE ALCOHOL VIOLATIONS)
Data Elements, front, page 1 (Original)

1. Insert court case number. 14. Check “yes” or “no” box. If ordered,
insert name(s) and address(es) of
2. Insert court jurisdiction. Check Alcohol Rehabilitation Program and, if
applicable type of court. applicable, service providers. Also,
include dates and times of meetings (if
3. Insert name of offender. Insert name as known at time of issuance) of Program
it appears on driver’s license if a or service providers (example: “First
restricted driver’s license is ordered by Wed. 7:30-4:30 P.M.”). See also Data
the judge to be issued. Element No. 17. Strike through
remainder of blank line(s) to prevent
4. Insert current address of offender. The unauthorized additions.
current address name not agree with the
address shown on the driver’s license. 15. Insert net program fee which the
offender must pay.
5. Insert information describing the
offender. See Using This Form, 4.f. 16. Check the applicable box.

6. Insert driver’s license number of the 17. Check appropriate box to indicate if a
offender and state of issuance. See restricted driver’s license is to be issued.
Using This Form, 4.g.
18. Insert date on which restricted privilege
7. Insert date on which offense was to drive commences. See Using This
committed. Form, 4.h.

8. Check the applicable box(es) to show 19. Insert expiration date of this restriction.
whether the conviction was based on See Using This Form, 4.i.
intoxication from alcohol, drugs or both,
if applicable. 20. Check box if there are other conditions,
and list these other conditions on the
9. Check the box noting whether this is the reverse side of this form.
original or amended order.

10. Check box to indicate offense for which

this restricted license is being issued.

11. Insert period of time for which the

driver’s license is suspended.

12. Check box to indicate date from which

the beginning of the suspension period
is calculated for juvenile.

13. Indicate by checking the appropriate box

under which code section the adult
defendant was tried.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2011
Other applicable conditions:
1
...........................................................................................................................................................................................................................................

This is to certify that the offender described on the front of this Order has enrolled in the Program named
in this Order.

2
............................................
3
................................................................................. 4
____________________________________________
DATE TITLE SIGNATURE

FORM DC-576 (REVERSE, PAGE ONE OF THREE) 07/10

Form DC-576 DRIVER’S LICENSE DENIAL ORDER (JUVENILE)/ Form DC-576
DRIVER’S LICENSE SUSPENSION ORDER
(UNDERAGE ALCOHOL VIOLATIONS)

Data Elements, reverse, page 1, (Original)

1. Describe other applicable conditions other than the terms on the second and third pages
of the order.

2. Date of completion of reverse of this form by staff member of program.

3. Title of program staff member completing the reverse of this form.

4. Signature of program staff member completing the reverse of this form.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2011
Form DC-577 DRIVER’S LICENSE SUSPENSION ORDER AND Form DC-577
ENTRY INTO SERVICE PROGRAM (JUVENILE)

Using This Form

1. Copies

a. Original – to juvenile.

b. First copy – to court.

c. Second copy – to Division of Motor Vehicles.

d. Third copy – to services program (such as Alcohol Rehabilitation Program).

2. Prepared by clerk, signed by judge and juvenile.

3. Attachments – (to Division of Motor Vehicles copy ONLY).

a. Driver’s license if suspended or revoked or a restricted license ordered.

b. District court form DC-210, ACKNOWLEDGEMENT OF SUSPENSION OR REVOCATION OF

DRIVER’S LICENSE, (if judge does not order the issuance of a restricted driver’s license).

4. Preparation details

a. If a juvenile is ordered into a program for a non-traffic offense pursuant to Virginia Code
§ 16.1-278.8(9), then use this order. For juveniles charged with driving while intoxicated
or certain alcohol or drug-related offenses, use DC-576, DRIVER'S LICENSE DENIAL
ORDER (JUVENILE). This is a three-page order. The second and third pages to be used
with this form are designated as district court form DC-261, RESTRICTED DRIVER’S
LICENSE.

c. This form must be used whenever a juvenile enters a services program, such as Alcohol
Rehabilitation Program, even if the issuance of a restricted license is not ordered.
VASAP (if applicable) and DMV will use this form to provide better record-keeping
regarding services program participants.

d. The defendant should be required to surrender his copy of the pre-existing order (if the
pre-existing order permitted the issuance of a restricted driver's license) before giving an
amended order to the juvenile.

e. Do not prepare an abstract of conviction to accompany a copy of the order being sent to
the Division of Motor Vehicles. This order form serves as the abstract of disposition
required by Virginia Code § 16.1-278.8(9).

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2011
Form DC-577 DRIVER’S LICENSE SUSPENSION ORDER AND Form DC-577
ENTRY INTO SERVICE PROGRAM (JUVENILE)

Using This Form, continued

f. The identification information in this form is found on all warrants and summonses,
including the Virginia Uniform Summons. It is used to identify the juvenile who is
driving solely on this order pending a re-issuance of his driver's license by the
Department of Motor Vehicles.

Verify that the date of birth agrees with the birth date shown on the driver’s license.

g. The driver's license number is used by the Virginia Department of Motor Vehicles for
driver's license re-issuance and records updating. The arresting officer uses it for radio
records checks and matching the order to the driver's license.

If the defendant does not have a driver's license, use the offender's social security number
followed by "(SSN)." This data requirement does not authorize the issuance of a
restricted license order if the defendant does not otherwise have a valid driver's license at
the time of conviction.

h. If services program meeting time or information concerning the service provider is

unknown when original order is entered, such additional information may be provided on
an amended order or by a supplemental document from the services program. See Data
Element No. 12.

i. Data Element No. 16 may be used to postpone the commencement of the restricted
driving privilege so that the juvenile has, as a learning experience, a short period of time
without being permitted to drive.

j. In setting the expiration date in Data Element No. 17, the judge should consider:

− the estimated successful completion date of Program participation by the juvenile.

− the effect of any mandatory or discretionary license suspension imposed in this case
which comes into effect when the order expires.

No action by the court is required to restore the regular driver’s license of the juvenile
when this order expires.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2011
DRIVER’S LICENSE SUSPENSION ORDER AND 1
Case No: .............................................................
ENTRY INTO SERVICES PROGRAM (JUVENILE)
Commonwealth of Virginia Va. Code §§ 16.1-278.8(9), 16.1-278.5(B)(2)
5 COMPLETE DATA BELOW IF KNOWN
[ ] Circuit Court RACE SEX BORN HT. WGT. EYES HAIR

2
................................................................................................... [ ] Juvenile and Domestic MO. DAY YR. FT. IN.

CITY/COUNTY Relations District Court D.L.# STATE

3
................................................................................................... 6
JUVENILE

4
................................................................................................... 7
...................................................... [ ] Original Order
ADDRESS OFFENSE DATE 8
[ ] Amended Order
...................................................................................................
CITY STATE ZIP

You [ ] have been found guilty of a non-traffic delinquency and disposition of this case is being made pursuant to § 16.1-278.8(9).
[ ] have been found in need of supervision and disposition of this case is being made pursuant to § 16.1-278.5(B)(2).
[ ] have previously been found to be in need of supervision and have been found to have willfully and materially violated the order
of the court or the terms of the probation pursuant to § 16.1-291(C).
9 [ ] have been found to have 10 or more unexcused absences from a public school on consecutive school days pursuant to § 46.2-
334.001. A restricted driver’s license can be issued only if you are employed at least four hours per day and at least 20 hours per
week, you have a medical condition that requires you to be able to drive a motor vehicle, or you are the only licensee in your
household.
As part of the disposition,
1.10[ ] Your driver’s license and privilege to drive are ORDERED suspended for a period of 11
.........................................................................................
2.12[ ] yes [ ] no You are ORDERED, on the terms and conditions listed below, to enter the following Services Program (the Program):
12
...................................................................................................................................................................
13
[ ] Drugs [ ] Alcohol: 14
...................... B.A.C.
PROGRAM NAME

3. [ ] No restricted license privilege is granted to you by this ORDER.

15
[ ] A restricted license privilege is granted to you for the purposes enumerated on the second and third pages of this Order and
subject to the conditions below.
CONDITIONS OF RESTRICTED LICENSE: This ORDER is entered and the restricted license is to be issued upon the following
conditions:
(1) This privilege is further subject to any other conditions, restrictions, suspensions or revocations imposed by any court of
competent jurisdiction or the Virginia Department of Motor Vehicles. If your license is suspended for other reasons, the
privileges of this license may be VOID and the Department of Motor Vehicles may refuse to issue you a restricted license.
(2) If so ordered, you will promptly complete your entry into the Program and will satisfactorily and timely comply with and complete
the Program’s requirements.
(3) You shall carry ALL THREE PAGES of this ORDER, and any attachment, at all times while operating a motor vehicle until this
restricted license expires. You will carry a copy of this order together with the restricted license to be issued by the Virginia
Department of Motor Vehicles upon receipt of such restricted license or by your home state license if you are not a Virginia resident.
(4) 16
.......................................................... Commencement date of restricted license privilege. This privilege EXPIRES 60 DAYS from this date
if this ORDER is not accompanied by a restricted license issued by the Virginia Department of Motor Vehicles or by your home
state license if you are not a Virginia resident.
(5) 17
.......................................................... Expiration date of this restricted license Order unless withdrawn or modified by this Court. Upon
expiration of this restricted license Order, issuance of a driver’s license shall be subject to other conditions, restrictions, suspensions
or revocations imposed by any court of competent jurisdiction or the Virginia Department of Motor Vehicles.
(6) You shall immediately notify this Court, the Virginia Department of Motor Vehicles, and the Program of any change of residential
address; or of any change to any of the information listed in items “a” through “m” on pages two and three of this Order.
18
[ ] Please see reverse side for other applicable conditions.
WARNING: Forging or altering this Order or possessing a forged or altered order is a separate criminal offense punishable by fines and
incarceration. Va. Code §§ 18.2-107, 18.2-168, 18.2-169. Driving outside of these restricted privileges constitutes a separate criminal offense.
.

NOTE: This is page one of a three-page order.

FORM DC-577 (FRONT, PAGE ONE OF THREE) 07/11

Form DC-577 DRIVER’S LICENSE SUSPENSION ORDER AND Form DC-577
ENTRY INTO SERVICE PROGRAM (JUVENILE)

Data Elements, page one, front

1. Court case number.

2. Court jurisdiction. Check applicable type of court.

3. Name of juvenile. Insert name as it appears on driver’s license if a restricted driver’s license is
ordered by the judge to be issued.

4. Current address of juvenile. The current address may not agree with the address shown on the
driver’s license.

5. Information describing the juvenile. See “Using This Form,” 4.f.

6. Driver’s license number of the juvenile and state of issuance. See “Using This Form,” 4.g.

7. Date on which offense was committed.

8. Check the applicable box. If this order is an amended order, see “Using This Form.”

9. Check the appropriate box.

10. If applicable, check this box.

11. If Data Element No. 10 is checked, insert period of time for which the driver’s license is
suspended.

12. If applicable, check this box and insert name(s) and address(es) of services program and, if
applicable, service providers. Also include dates and times of meetings (if known at time of
issuance) of Program or service providers (example: “First Wed. 7:30-4:30 P.M.”) and the
Program fee. Strike through remainder of blank line(s) to prevent unauthorized additions.

13. Check applicable box(es) to show whether the conviction was based on intoxication from alcohol,
drugs or both, if applicable.

14. If Data Element No. 13 is checked “alcohol” add the blood alcohol content from test results
admitted into evidence in court. If none was admitted, insert “not available.”

15. Check appropriate box to indicate if a restricted driver’s license is to be issued.

16. Date on which restricted privilege to drive commences. See “Using This Form,” 4.i.

17. Expiration date of this restriction. See “Using This Form,” 4.j.

18. Check box if there are other conditions list these other conditions on the reverse side of this form.

DISTRICT COURT MANUAL FORMS VOLUME

This is to certify that the offender described on the front of this Order has enrolled in the Program named in this
Order.

2
............................................ 3
.......................................................................................... 4
____________________________________________________
DATE TITLE SIGNATURE

FORM DC-577 (REVERSE, PAGE ONE OF THREE) 07/10

Form DC-577 DRIVER’S LICENSE SUSPENSION ORDER AND Form DC-577
ENTRY INTO SERVICE PROGRAM (JUVENILE)

Data Elements,
page one, reverse (Original)

1. Describe other applicable conditions other than terms on the second and third pages of
the order.

2. Date of completion of reverse of this form by staff member of program.

3. Title of program staff member completing the reverse of this form.

4. Signature of program staff member completing the reverse of this form.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2011
Form DC-578 RESTRICTED DRIVER’S LICENSE Form DC-578

Using This Form

1. Copies

a. Original – to juvenile.

b. First copy – to court.

c. Second copy – to Division of Motor Vehicles.

2. Prepared by clerk, signed by judge and offender.

3. Attachments – none.

4. Preparation details

a. This restricted driver’s license is to be used in those cases under Virginia Code
§ 46.2-334.01 where a juvenile whose license has been suspended
administratively for 90 days requests a restricted driver’s license. It may only be
issued for travel to and from the juvenile’s home, the juvenile’s place of
employment, or the institution of higher learning where the juvenile is enrolled.

b. The original of this 3-part set is printed on safety paper (like bank checks) to
prevent forgery and tampering. Do not try to make corrections as changes cannot
be made on safety paper. If an error is made, the entire form must be retyped.

c. The identification information is used to identify the juvenile who is driving

solely on this order pending a reinstatement and return of his driver’s license.
Verify that the date of birth agrees with the birth date shown on the driver’s
license or on the Department of Motor Vehicles transcript.

d. The driver’s license number is used by the Virginia Department of Motor

Vehicles for driver’s license records updating. The arresting officer uses it for
radio records checks and matching the order to the driver’s license.

e. Data Element No. 11 may be used to postpone the commencement of the

restricted driving privilege so that the juvenile has, as a learning experience, a
short period of time without being permitted to drive.

f. No action by the court is required to restore the regular driver’s license to a

juvenile when this order expires.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2011
RESTRICTED DRIVER’S LICENSE
Commonwealth of Virginia Va. Code §§ 46.2-334.01 Case No. 1
.....................................................................................

[ ] Circuit Court
2
........................................................................................................................ [ ] Juvenile and Domestic Relations District Court
CITY/COUNTY

3
........................................................................................................................ RACE SEX
COMPLETE DATA BELOW IF KNOWN
BORN HT. WGT. EYES HAIR
JUVENILE
MO. DAY YR. FT. IN.
4
........................................................................................................................ 5
ADDRESS DL# STATE

6
........................................................................................................................
CITY STATE ZIP 7 [ ] Original Order [ ] Amended Order
Your driver’s license and privilege to drive has been suspended for a period of 90 days by the
Commissioner of the Virginia Department of Motor Vehicles pursuant to Va. Code § 46.2-334.01. You have
requested that a restricted driver’s license be issued.
8 [ ] No restricted license privilege is granted to you by this ORDER.
9 [ ] A restricted license privilege is granted to you for the sole purpose of traveling to and from your home, your
place of employment, or the institution of higher learning where you are enrolled.
10
.................................................................................................................................................................................................................................................
EMPLOYER NAME AND WORK LOCATION

10
.................................................................................................................................................................................................................................................
HOURS FOR TRAVEL TO AND FROM WORK

11
.................................................................................................................................................................................................................................................
NAME AND LOCATION OF INSTITUTION OF HIGHER LEARNING

11
.................................................................................................................................................................................................................................................
DATES AND TIMES FOR TRAVEL TO AND FROM INSTITUTION OF HIGHER LEARNING

12 [ ] You must carry your work and/or school schedule with this Order while operating a motor vehicle.

CONDITIONS OF RESTRICTED LICENSE: This ORDER is entered and the restricted license is to be
issued upon the following conditions:
(1) This privilege is subject to any other conditions, restrictions, suspensions or revocations imposed
by any court of competent jurisdiction or the Virginia Department of Motor Vehicles. If your
license is suspended for other reasons, the privileges of this license may be VOID.
(2) You shall carry this ORDER at all times while operating a motor vehicle until this restricted license
expires.
(3) 13
....................................................................... Commencement date of restricted license privilege.
(4) 14
....................................................................... Expiration date of this restricted license Order unless withdrawn or
modified by this Court. Upon expiration of this restricted license Order, issuance of a driver’s license
shall be subject to other conditions, restrictions, suspensions or revocations imposed by any court of
competent jurisdiction or the Virginia Department of Motor Vehicles.
(5) You shall immediately notify this Court, and the Virginia Department of Motor Vehicles of any change
of residential address, any change of employer, employment location or work schedule, and any change
of institution of higher learning, enrollment, location or schedule.

15
....................................................................... 16
_____________________________________________________________
DATE JUDGE

WARNING: Forging or altering this Order or possessing a forged or altered order is a separate offense punishable by fines and
incarceration. Va. Code §§ 18.2-107, 18.2-168, 18.2-169. Driving outside of these restricted privileges constitutes a separate offense.

FORM DC-578 REVISED 07/11

Form DC-578 RESTRICTED DRIVER’S LICENSE Form DC-578

Data Elements

1. Insert court case number.

2. Insert court jurisdiction. Check applicable type of court.

3. Insert name of juvenile. Insert name as it appears on driver’s license if a restricted

driver’s license is ordered by the judge to be issued.

4. Insert current address of juvenile. The current address may not agree with the address
shown on the driver’s license.

5. Insert information describing the juvenile. See Using This Form, 4.c.

6. Insert driver’s license number of the juvenile and state of issuance. See Using This
Form, 4.c.

7. Check box noting whether this is the original or amended order.

8. Check this box if no restricted license privilege is granted.

9. Check this box if a restricted license privilege is granted.

10. If the restricted license privilege is granted, note the name and address of the employer
and the hours of travel to and from work.

11. If the restricted license privilege is granted, note the name and location of institution of
higher learning and the dates and times for travel to and from institution of higher
learning.

12. Check this box if a restricted license privilege is granted.

13. Insert the date on which the restricted privilege to drive commences. See Using This
Form, 4.d.

14. Insert the expiration date of this restriction.

15. Date the order is entered.

16. Judge’s signature.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2011
Form DC-580 NOTICE OF APPEAL – CRIMINAL Form DC-580

Using This Form

1. Copies

a. Original – to court.

b. First copy – to appellant.

2. Prepared by clerk, signed by appellant.

3. Attachments

District court form DC-330, RECOGNIZANCE – if released while the appeal is pending.

4. Preparation Details

a. All appeals must be noted in writing. Because this form contains information
concerning the appellant’s rights and obligations, its use is strongly recommended.

b. This form is designed for use in juvenile and adult criminal appeals and from
domestic relations district court to a circuit court.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2013
NOTICE OF APPEAL – CRIMINAL VA. CODE §§ 16.1-132, 16.1-133, 16.1-296, 16.1-298 CASE NO.
17
1
.................................................................................................................... Juvenile and Domestic Relations District Court
CITY OR COUNTY
NOTICE OF APPEAL
2
....................................................................................................................
DATE OF FINAL ORDER
[ ] Commonwealth of Virginia
3 I, the undersigned, appeal [ ] this final order or judgment [ ] the determination on bail to the Circuit Court 18 [ ] City [ ] County [ ] Town of
named below. I understand that this appeal may be withdrawn at any time prior to the hearing date set forth for
this case. 18
.............................................................................................................
v.
4 This case is scheduled to be called for [ ] hearing on appeal of determination of bail [ ] trial [ ] setting of trail
date on 19
.............................................................................................................
5 6
.
DEFENDANT’S NAME (LAST, FIRST, MIDDLE)
..................................................................... in the ................................................................................................... Circuit Court
.
DATE AND TIME OF APPEARANCE 20
.............................................................................................................
7
at .............................................................................................................................................................................................................
ORIGINAL CHARGE

STREET ADDRESS OF CIRCUIT COURT TELEPHONE 21

.............................................................................................................
. APPELLANT

8[ ] This appeal is filed in a case involving the release of a juvenile over the objection of the Commonwealth.
.............................................................................................................
9[ ] I am requesting a stay of the execution of the bail determination order. ADDRESS

I understand that if this appeal is withdrawn within 10 days after my final order in this District Court, no .............................................................................................................
additional costs will be taxed against me; otherwise, additional costs may be incurred in the Circuit Court. I also
.............................................................................................................
understand that upon withdrawal of this appeal, I must comply with the terms of the final order or judgment. TELEPHONE #

WARNING – If you fail to appear, you are subject to a conviction and judgment in your absence being entered WITHDRAWAL
against you in the Circuit Court. Failure to appear shall be deemed a waiver of your right to trial by jury in this I, the undersigned, withdraw my appeal in this case.
case. Failure to appear may also constitute a separate criminal offense. 22
....................................................
DATE
I promise to appear before the Circuit Court of this jurisdiction at the date and time shown. 23
______________________________________________________
10
....................................................................................... 11
____________________________________________________
APPELLANT

DATE OF APPEAL APPELLANT [ ] DEFENDANT [ ] PROSECUTING ATTORNEY 24

by ___________________________________________________
ATTORNEY FOR APPELLANT

12
....................................................................................... by 13
_________________________________________________
NAME OF ATTORNEY FOR DEFENDANT APPELLANT ATTORNEY FOR DEFENDANT APPELLANT

NOTICE: Promptly communicate with the Clerk of the Circuit Court of this jurisdiction concerning the COURT USE ONLY
subpoenaing of witnesses and any need for interpreters, concerning your right of representation by a lawyer if [ ] Release on $ ......................................................
you do not have a lawyer, and if you wish to request a jury trial. If your case is scheduled for trial, you MUST 25 (CASH OR SURETY)
be present and ready for trial at the “date and time of appearance: shown above.
$ ......................................................
(REALTY)
ORDER
The request for stay of execution of bail determination order is $ ......................................................
(PERSONAL RECOGNIZANCE)
[ ] Granted, upon good cause shown, and the bail determination order is stayed until .......................................
14 DATE AND TIME [ ] Not eligible for bond
[ ] Denied. 26
15
....................................................................................... 16
_______________________________________________________
DATE JUDGE

FORM DC-580 MASTER 07/13

Form DC-580 NOTICE OF APPEAL – CRIMINAL Form DC-580

Data Elements

1. Insert jurisdiction name. 18. Indicate the entity prosecuting the case.

2. Insert date of final order. 19. Indicate the name of the defendant.

3. Check the appropriate box to indicate the 20. Insert the original charge.
purpose of appeal.
21. Insert name, address and telephone number
4. Check the appropriate box to indicate the of appellant.
purpose of appearance in circuit court.
22. Insert date on which appeal was withdrawn,
5. Insert date and time of appearance. if applicable.

6. Insert name of circuit court to which case 23. Signature of appellant withdrawing his
being appealed. appeal if withdrawn by appellant. Type or
print name if appeal withdrawn by attorney.
7. Insert street address of circuit court and the
telephone number of the circuit court clerk’s 24. Signature of attorney when attorney
office. withdraws appeal.

8. Check this box, if applicable. 25. If appellant released on bond, check this box
and complete the appropriate lines.
9. Check this box if a stay of the execution of
the bail determination order is being 26. Check this box if the court does not permit
requested. the appellant to be released prior to
completion of the appeal.
10. Insert date on which appeal is noted.

11. Signature of adult or juvenile appellant or

prosecuting attorney if he noted the appeal.
Type or print name if appeal noted by
attorney. Check box to identify appellant.

12. Print name of attorney if attorney noted

appeal on behalf of defendant appellant.

13. Signature of attorney if attorney noted

appeal on behalf of defendant appellant.

14. Check applicable box. If request for stay of

execution of bail determination is granted,
insert date and time for when bail
determination order is stayed until.

15. Date signed by judge.

16. Signature of judge.

17. Insert court case number.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2013
Form DC-581 NOTICE OF APPEAL – JUVENILE CIVIL APPEALS Page: 1

Using This Form

1. Copies

a. Original – to court.

b. First copy – to appellant.

2. Prepared by clerk, signed by appellant.

3. Attachment – case papers for case being appealed.

4. Preparation details – setting trial date in circuit court on appeal cases.

a. Complete Data Element No. 4 by specifying the type of case being appealed.

b. Complete Data Elements Nos. 5, 6, and 7 if circuit court has pre-set trial date for district
court cases (first check box in Data Element No. 6) or pre-set docket call date on which
district court cases will be called for setting the trial date (second check box in Data
Element No. 6). Call the clerk’s office or judge’s secretary for an expedited hearing date
in termination of parental rights cases.

DISTRICT COURT FORMS MANUAL JULY 2008

Form DC-581 NOTICE OF APPEAL – JUVENILE CIVIL APPEALS Page: 2
NOTICE OF APPEAL—Juvenile Civil Appeals VA. CODE §§ 16.1-106.1, 16.1-277.01, 16.1-277.02, 16.1-278.15, 16.1-
278.2, 16.1-278.3, 16.1-278.4, 16.1-281, 16.1-282, 16.1-282.1, 16.1-283, JDR CASE NO. 15
16.1-296, 16.1-296.2, 16.1-298, 20-107.2 ........................................................
1
............................................................................................... Juvenile and Domestic Relations District Court
CITY OR COUNTY Circuit Court CASE NO. CJ- . . . . . . . . .16
...........................
2
............................................................................................... 3
..............................................................
DATE OF FINAL ORDER CHILD’S DATE OF BIRTH
In re: 17
...........................................................................
I, the undersigned, note my appeal of the final dispositional order of this court to the circuit court of this county or city. CHILD’S NAME (LAST, FIRST, MIDDLE)
[ ] Abuse/Neglect [ ] Relief of Custody/Entrustment
[ ] Custody [ ] Initial Foster Care Plan
[ ] Visitation [ ] Foster Care Review NOTICE OF APPEAL
[ ] CHINS 4 [ ] Permanency Planning Hearing
[ ] Paternity [ ] .........................................................................................
[ ] Termination of Parental Rights. 6 18
...................................................................................
Pursuant to § 16.1-296(D) of the Code of Virginia, the circuit court shall hold a hearing on the merits of an appeal APPELLANT’S NAME (LAST, FIRST, MIDDLE)
of a termination of parental rights case within 90 days of the perfecting of the appeal.
[ ] My case is scheduled to be called for [ ] trial [ ] setting of trial date on
...................................................................................
5 7
ADDRESS
...........................................................................................................................................................
DATE AND TIME OF APPEARANCE ...................................................................................
8
...........................................................................................................................................................
STREET ADDRESS OF CIRCUIT COURT
19
...................................................................................
I understand that the order of judgment which I am appealing remains in full force and effect until changed or annulled
by the Circuit Court. I promise to appear before the circuit court of this jurisdiction at the date and time shown. To the ...................................................................................
best of my knowledge, I expect the time requirement for this hearing to be . . . . . . . . . . . . . . . . . . . . . . . . 9
. . . . . . . . . . . . . . . . . . . . . . . . . hours.

10 11 ...................................................................................
........................................................ ______________________________________________________________________ RELATIONSHIP TO CHILD
DATE OF APPEAL APPELLANT

12
By ___________________________________________________________________ Custody and Visitation Cases:
ATTORNEY FOR APPELLANT

Name of Guardian ad litem: 13

__________________________________________________________ $ 20 Circuit Court Writ Tax, Costs
.......................................
and Service Fees. Fees are required for all custody and
14
Name of Attorney for Appellee: _______________________________________________________ visitation petitions simultaneously appealed by petitioner.
NOTICE: Promptly communicate with the Clerk of the Circuit Court of this jurisdiction concerning the subpoenaing of WITHDRAWAL
witnesses and any need for interpreters. Failure to appear in the circuit court at the designated date and time may I, the undersigned, withdraw my appeal in this case
result in the dismissal of your appeal.
21
.........................................................................................................
WITHDRAWAL OF APPEAL: If this appeal is withdrawn within ten (10) days after entry of the judgment or order when no DATE
appeal bond or costs are required to perfect the appeal, or before being “perfected” by posting required appeal bond or paying
required costs, no additional costs will be taxed against you. After ten (10) days or after the appeal is “perfected” by posting 22
___________________________________________________
APPELLANT
the required appeal bond or paying required costs, in accordance with § 16.1-106.1, any withdrawal of the appeal must occur
in Circuit Court, Upon withdrawal of the appeal in Circuit Court, additional costs will be incurred and any cash bond posted to by ________________________________________________
23
perfect the appeal may be disbursed. ATTORNEY FOR APPELLANT

FORM DC-581 MASTER 07/08

DISTRICT COURT FORMS MANUAL JULY 2008

Form DC-581 NOTICE OF APPEAL – JUVENILE CIVIL APPEALS Page: 3

Data Elements
1. Jurisdiction name.

2. Date of final order of district court.

3. Child’s date of birth

4. Check appropriate box to indicate the type of case being appealed.

5. Check if pre-set docket call date or trial date in circuit court is to be given through the district court.

6. If Data Element No. 5 is checked, then check the first box if a pre-set trial date is given; if a pre-set
docket call date for setting trial is given, check the second box.

7. Insert date and time of scheduled appearance for reasons shown by Data Element No. 5 in circuit
court.

8. Insert street address of circuit court and the telephone number of the circuit court clerk’s office.

9. Indicate estimation of time needed for the hearing.

10. Date of noting of appeal.

11. Signature of appellant if he noted the appeal; print or type appellant's name if appeal noted by
appellant's attorney. Check applicable box indicating if appellant is plaintiff or defendant.

12. Signature of attorney when appeal noted by attorney.

13. Name of guardian ad litem appointed in juvenile and domestic relations district court, if applicable.

14. Name of attorney for the appellee appointed in juvenile and domestic relations district court, if
applicable.

15. Juvenile and domestic relations district court case number.

16. Circuit court case number.

17. Name of child.

18. Name and address of appellant.

19. Appellant’s relationship to the child.

20. Total amount of writ tax, costs and service of process fees required to be posted.

21. Date of withdrawal of appeal.

22. Signature of appellant or name of appellant if withdrawn by appellant’s attorney.

23. Signature of appellant’s attorney, if applicable.

DISTRICT COURT FORMS MANUAL JULY 2008

Form DC-582 REQUEST FOR VIRGINIA REGISTRATION Form DC-582
OF CHILD CUSTODY AND/OR
VISITATION DETERMINATION FROM ANOTHER STATE

Using This Form

1. Copies

a. Original - to court.

2. Prepared by person requesting registration.

3. Attachments - two copies of determination sought to be registered; one copy must be

certified.

4. Preparation Details

a. This form is intended for use in implementing the registration provision of the
Uniform Child Custody Jurisdiction and Support Act (UCCJEA), Virginia Code §§
20-146.1 through 20-146.38.

b. Any person having custody or visitation rights to a child under a determination from
another state may request registration of the determination in Virginia. The
registration is for enforcement purposes only.

c. After receipt of two copies of the foreign determination, at least one of which being
a certified copy, and a completed DC-582, the clerk must issue a form DC-583,
NOTICE OF REQUEST FOR VIRGINIA REGISTRATION OF A CHILD CUSTODY AND/OR
VISITATION DETERMINATION FROM ANOTHER STATE to be served on the non-
registering party, Virginia Code §§ 20-146.1. The non-registering party may request a
hearing if he/she wishes to contest the validity or enforcement of the registered
determination at any time.

d. The determination is registered upon receipt of the request.

e. If the box is checked requesting that information on this form be sealed, this
document must be placed in a sealed envelope in the file.

DISTRICT COURT MANUAL FORMS VOLUME

SEPTEMBER 2002
REQUEST FOR VIRGINIA REGISTRATION OF A CHILD
CUSTODY AND/OR VISITATION DETERMINATION
1
FROM ANOTHER STATE Case No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Commonwealth of Virginia Va. Code § 20-146.26

2
............................................................................. Juvenile and Domestic Relations District Court
CITY/COUNTY

. . . . . . . . . . .3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

COURT ADDRESS

5
In re: . . . . . . . . . . . 4
................................................................................. ...............................
NAME OF CHILD WHO IS SUBJECT OF DETERMINATION TO BE REGISTERED DATE OF BIRTH OF CHILD

Name of Person Requesting Registration: . . . . .6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7
Address of Person Requesting Registration: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.......................................................................................................................................

[ 8] I allege under oath that the health, safety or liberty of a party or child would be jeopardized by
disclosure of identifying information. Therefore, I request that this document be sealed pursuant to the
provisions of subsection E of Virginia Code § 20-146.20 and the address above not be disclosed.

Name and Address of Persons other than the person requesting registration who have been awarded custody or
visitation in the attached child custody and/or visitation determination:

9 10
......................................................... .............................................................
NON-REGISTERING PARTY OTHER INTERESTED PERSON

........................................................ ............................................................
ADDRESS ADDRESS

......................................................... .............................................................

I request that the clerk of the above-named court register the attached certified child custody and/or
visitation determination. Two copies (including at least one certified copy) of the child custody and/or visitation
determination are attached.

I state, under penalty of perjury, that to the best of my knowledge and belief, the attached child custody
and/or visitation determination has not been modified.

11 12
........................................................ ________________________________________________
DATE SIGNATURE OF REQUESTOR

Subscribed and sworn to before me this day by ...... .........................................................................

14
.........................................
15
________________________________________________
DATE [ ] CLERK [ ] DEPUTY CLERK [ ] MAGISTRATE
[ ] NOTARY PUBLIC My Commission Expires: . . . . . . . . . . . . . . . . . . . . . . . . .

FORM DC-582 (MASTER) REVISED 9/02

Form DC-582 REQUEST FOR VIRGINIA REGISTRATION Form DC-582
OF CHILD CUSTODY AND/OR
VISITATION DETERMINATION FROM ANOTHER STATE

Data Elements

1. Court case number.

2. Court name.

3. Court address.

4. Name of child who is the subject of determination to be registered.

5. Date of birth of child who is the subject of determination.

6. Name of the person who is requesting registration.

7. Address of person requesting registration.

8. Check this box if requestor requests that the information on the request not be
disclosed.

9. Name and address of non-registering party.

10. Name and address of other interested person.

11. Date signed by registering party.

12. Signature of registering party.

13. Name of person whose signature is being acknowledged.

14. Date signature acknowledged.

15. Signature of person acknowledging, and check appropriate title box. If it is a notary,
insert the date the notary’s commission expires.

DISTRICT COURT MANUAL FORMS VOLUME

SEPTEMBER 2002
Form DC-583 NOTICE OF REQUEST FOR VIRGINIA Form DC-583
REGISTRATION OR A CHILD CUSTODY AND/OR
VISITATION DETERMINATION FROM ANOTHER STATE

Using This Form

1. Copies

a. Original – to court.

b. First copy to non-registering party.

c. Second copy to registering party.

2. Prepared by clerk or deputy clerk.

3. Attachments –

a. Form DC-582, REQUEST FOR VIRGINIA REGISTRATION OF A CHILD CUSTODY

AND/OR VISITATION DETERMINATION FROM ANOTHER STATE.

b. Foreign child custody or visitation determination pertaining to request.

c. Any other documents and relevant information accompanying the determination.

4. Preparation details

a. This form is intended for use with the form DC-582, REQUEST FOR VIRGINIA
REGISTRATION OF A CHILD CUSTODY AND/OR VISITATION DETERMINATION FROM
ANOTHER STATE, to implement the registration provisions of the Uniform Child
Custody Jurisdiction and Support Act (UCCJEA), Virginia Code §§ 20-146.1
through 20-146.38.

b. Upon receipt of a completed form DC-582, REQUEST FOR VIRGINIA

REGISTRATION OF A CHILD CUSTODY AND/OR VISITATION DETERMINATION FROM
ANOTHER STATE, the clerk should prepare form DC-583. Copies of the completed
forms DC-582, DC-583, the foreign custody and/or visitation determination
pertaining to the request and any other documents and relevant information
accompanying the determination should be served on the non-registering party.
Do not include the DC-582 if non-disclosure is requested.

c. The non-registering party may request a hearing to contest the registration at any
time, Virginia Code § 20-146.26.

DISTRICT COURT MANUAL FORMS VOLUME

JANUARY 2013
NOTICE OF REQUEST FOR VIRGINIA Case No. 1
....................................................................................
REGISTRATION OF A CHILD CUSTODY
AND/OR VISITATION DETERMINATION
FROM ANOTHER STATE
Commonwealth of Virginia Va. Code § 20-146.26

2
............................................................................................................................................... Juvenile and Domestic Relations District Court
CITY/COUNTY

A request for registration of the attached child custody and/or visitation determination dated
5
..................................................................... has been filed by 6
........................................................................................................................................
DATE NAME OF PERSON REQUESTING REGISTRATION
with this court pursuant to Virginia Code § 20-146.26.

In accordance with the request and Virginia Code § 20-146.26, this child custody and/or visitation determination
has been filed as a foreign judgment and may be enforced by this court.

If you wish to contest the registration of this child custody and/or visitation determination, you must file a written
request for a hearing in the clerk’s office of this court.

7
_____________________________________________________________
[ ] CLERK [ ] DEPUTY CLERK

RETURNS: Each person was served according to law, as indicated below, unless not found.

NAME: ..................................................................................................... NAME: ......................................................................................................

8
ADDRESS: .............................................................................................. 8
ADDRESS: ................................................................................................

9 [ ] PERSONAL SERVICE TEL. NO. ............................................ 9 [ ] PERSONAL SERVICE TEL NO. .............................................

[ ] Being unable to make personal service, a copy was delivered [ ] Being unable to make personal service, a copy was delivered
in the following manner: in the following manner:
10 10
[ ] Delivered to family member (not temporary sojourner or [ ] Delivered to family member (not temporary sojourner or
guest) age 16 or older at usual place of abode of party named guest) age 16 or older at usual place of abode of party named
above after giving information of its purpose. List name, age above after giving information of its purpose. List name, age
of recipient, and relation of recipient to party named above. of recipient, and relation of recipient to party named above.
11
......................................................................................................... 11
...........................................................................................................
......................................................................................................... ...........................................................................................................

[ ] Posted on front door or such other door as appears to be the [ ] Posted on front door or such other door as appears to be the
main entrance of usual place of abode, address listed above. main entrance of usual place of abode, address listed above.
(Other authorized recipient not found.) (Other authorized recipient not found.)

12 [ ] Not Found 14
_______________________________ 12[ ] Not Found 14
_______________________________
SERVING OFFICER SERVING OFFICER
13
........................... 15
for ______________________________________ 13
........................... 15
for ______________________________________
DATE DATE

FORM DC-583 MASTER 10/12

Form DC-583 NOTICE OF REQUEST FOR VIRGINIA Form DC-583
REGISTRATION OR A CHILD CUSTODY AND/OR
VISITATION DETERMINATION FROM ANOTHER STATE

Data Elements

1. Court case number.

2. Court name.

3. Court street address.

4. Name of child who is the subject of determination to be registered.

5. Date request was filed.

6. Name of person requesting registration.

7. Signature of clerk or deputy clerk.

8. Name, address and telephone number of person to be served.

9. Check if personal service made.

10. Check if substituted service made, and check appropriate box to indicate what type of service
was made.

11. Insert name, age and relation of recipient to party if delivered to a family member at party's
usual place of abode.

12. Check if not found.

13. Date service made.

14. Signature of serving officer.

15. Name of sheriff.

DISTRICT COURT MANUAL FORMS VOLUME

JANUARY 2013
Form DC-584 SUPPLEMENT TO PETITION FOR EXPEDITED Form DC-584
ENFORCEMENT UNDER VIRGINIA CODE § 20-146.29
OF THE UNIFORM CHILD CUSTODY AND ENFORCEMENT ACT

Using This Form

1. Copies - same number as petition to which it is attached.

2. Prepared by petitioner and attached to petition.

3. Attachments - DC-511, PETITION.

4. Preparation Details.

a. This Form should be completed and attached to the DC-511, PETITION, when expedited
enforcement of foreign custody and/or visitation determination is requested pursuant to
Virginia Code § 20-146.29.

b. Expedited enforcement can only be used for out-of-state determinations.

c. This information is required under Virginia Code § 20-146.29. A petition for expedited
enforcement cannot go forward without it.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2001
SUPPLEMENT TO PETITION FOR EXPEDITED Case No. . . . . . . . . . . .1. . . . . . . . . . . . . . . . . . . . .
ENFORCEMENT UNDER VIRGINIA CODE § 20-146.29
OF THE UNIFORM CHILD CUSTODY AND ENFORCEMENT ACT
Commonwealth of Virginia Va. Code §§ 20-146.29; 20-146.32

1. Did the court that issued the child custody determination upon which this enforcement action is based
identify the jurisdictional basis upon which it relied in exercising jurisdiction?
[ ] Yes [ ] No If yes, what was the basis: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.......................................................................................................................................................................

2. Has the child custody determination upon which this enforcement action is based been vacated, stayed or
modified by any court whose decision must be enforced under this act?
[ ] Yes [ ] No If yes, please provide the following information:

Name and location of court(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Case Number(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nature of Proceeding: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. Has any proceeding been commenced in a court of any State or foreign country that could affect the current
proceeding, including but not limited to proceedings related to custody, visitation, paternity, support,
domestic violence, protective orders, abuse and neglect, termination of parental rights, and adoptions?
[ ] Yes [ ] No
4
Name and location of court(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Case Number(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nature of Proceeding: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Present physical address of the child: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

...................................................................

.........................................................................................................................................................................

Present physical address of the Respondent: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

.........................................................................

...........................................................................................................................................................................

5. Is relief other than the immediate physical custody of the child and attorney’s fees being requested?
[ ] Yes [ ] No If yes, what relief is being sought (additional relief would include the assistance of
law enforcement officials)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
............................................................................

............................................................................................................................................................................

6. Has the child custody determination upon which this enforcement action is based been registered in any
other court? [ ] Yes [ ] No If yes, please provide the date(s) and place(s) of registration:
.......................................................................................................................................................................
8
.......................................................................................................................................................................

7. [ ] I, the Petitioner, request that the court issue an ex parte order that the child be taken into immediate
9 physical custody because the child is imminently likely to suffer serious physical harm or be removed
from the Commonwealth of Virginia.

This supplement is incorporated into the PETITION to which the supplement is attached.

FORM DC-584 (MASTER) 12/01

Form DC-584 SUPPLEMENT TO PETITION FOR EXPEDITED Form DC-584
ENFORCEMENT UNDER VIRGINIA CODE § 20-146.29
OF THE UNIFORM CHILD CUSTODY AND ENFORCEMENT ACT

Data Elements

1. Case number.

2. Check appropriate box. If "yes" is checked, provide basis for jurisdiction.

3. Check appropriate box. If "yes" is checked, provide name and location of court(s), case
number(s), and nature of proceedings.

4. Check appropriate box. If "yes" is checked, provide name and location of court(s), case
number(s), and nature of proceedings.

5. Provide address where child who is the subject of this proceeding is located at the time of
filing of petition.

6. Provide address where respondent is located at time of filing of petition.

7. Check applicable box. If "yes" is checked, indicate what further relief is sought.

8. Check applicable box. If "yes" is checked, provide date(s) and place(s) of registration.

9. Check this box if an ex parte order is requested.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2001
NOTICE TO RESPONDENT IN ENFORCEMENT PROCEEDING
UNDER VIRGINIA CODE § 20-146.29 OF THE UNIFORM CHILD
CUSTODY JURISDICTION AND ENFORCEMENT ACT
Commonwealth of Virginia Va. Code § 20-146.29

TO RESPONDENT:

At the hearing referenced in the attached SUMMONS, the court:

1. will order that the Petitioner may take immediate physical custody of the child; and
2. will order the payment of fees, costs and expenses under Virginia Code § 20-146.33; and
3. may schedule a hearing to determine whether further relief is appropriate.

UNLESS YOU APPEAR AND ESTABLISH THAT:

1. The child custody determination has not been registered under Virginia Code § 20-146.26
and that
a. the issuing court did not have jurisdiction under Article 2 (Virginia Code § 20-
146.12, et seq.) of the Uniform Child Custody Jurisdiction and Enforcement Act; or
b. the child custody determination for which enforcement is sought has been vacated,
stayed or modified by a court having jurisdiction to do so under Article 2 (Virginia
Code § 20-146.12 et seq.) of the Uniform Child Custody Jurisdiction and
Enforcement Act; or
c. you were entitled to notice, but notice was not given in accordance with the standards
of Virginia Code § 20-146.7 of the Uniform Child Custody Jurisdiction and
Enforcement Act, in the proceedings before the court that issued the order for which
enforcement is sought.
OR
2. The child custody determination for which enforcement is sought was registered under
Virginia Code § 20-146.26 but has been vacated, stayed, or modified by a court of a state
having jurisdiction to do so under Article 2 (Virginia Code § 20-146.12 et seq.) of the
Uniform Child Custody Jurisdiction and Enforcement Act.

FORM DC-585 (MASTER) 12/01

Form DC-586 EX PARTE ORDER TO TAKE PHYSICAL Form DC-586
CUSTODY OF A CHILD

Using This Form

1. Copies

a. Original – to court.

b. First copy – to officer who is ordered to take physical custody of the child.

c. Second copy – to person(s) to whom custody of juvenile is awarded.

d. Third copy – to person from whom physical custody of the child will be taken.

e. Fourth copy – to juvenile if of an age that the order will be understood.

f. Additional copies as determined by local practice.

2. Prepared by clerk, signed by judge.

3. Attachments – none.

4. Preparation details

a. This order is to be used only in cases involving the enforcement of an out-of-state

custody determination under the Uniform Child Custody Jurisdiction and
Enforcement Act.

b. This is an ex parte order that should only be used in extreme circumstances where
there is reason to find that the child is imminently likely to suffer serious physical
harm or be removed from the Commonwealth.

c. Data Element Nos. 13 and 14 – specific findings must be made to provide the
remedies in these two data elements. See Virginia Code § 20-146.29.

d. Data Element No. 16 – Unless it is impossible, the hearing must be set on the next
judicial day following issuance of this order.

DISTRICT COURT MANUAL FORMS VOLUME

JANUARY 2014
EX PARTE ORDER TO TAKE PHYSICAL Case No. 1
..................................................................................
CUSTODY OF A CHILD
(Uniform Child Custody Jurisdiction and Enforcement Act)
Commonwealth of Virginia Va. Code § 20-146.32
[ ] Circuit Court
2
............................................................................................................................... [ ] Juvenile & Domestic Relations District Court
In re: 3
..........................................................................................................................................................................................................................................................

4
has filed a petition requesting that this court
..............................................................................................................................................................
issue an ex parte order to take immediate physical custody of the above-named child based on an allegation that
the child is imminently likely to
[ ] suffer serious physical harm
5
[ ] be removed from this Commonwealth.
The petition contained the necessary information required by subsection B of Virginia Code § 20-146.29.

1. Following the presentation of testimony of 6

....................................................................................................................................................... ,

the court finds that 7

............................................................................................................................................. is imminently likely to
CHILD

[ ] suffer serious physical harm

8
[ ] be removed from this Commonwealth based on the following facts:
...............................................................................................................................................................................................................................................................
9
...............................................................................................................................................................................................................................................................

10
2. The above-named child is presently in the physical custody of ............................................................................................................
who resides at 11
............................................................................................................................................................................................................................

THEREFORE, the court ORDERS that:

1. 12
.................................................................................................................. take physical custody of the above-named child
LAW ENFORCEMENT AGENCY
immediately.
13 a. [ ] Based on the testimony received by this court, officers of .....................................................................................................

may enter private property to take physical custody of the above-named child.
14 b. [ ] Based on exigent circumstances, officers of .....................................................................................................................................
may forcibly enter private property at any hour to take physical custody of the above-named child.

15
2. The above-named child shall be placed with ......................................................................................................................................................
pending the hearing and final order in this matter.

A hearing in this matter is set for 16

........................................................................................................ at ........................................................ .
DATE TIME

17
....................................................................................... 18
________________________________________________________
DATE JUDGE

FORM DC-586 MASTER 10/13

Form DC-586 EX PARTE ORDER TO TAKE PHYSICAL Form DC-586
CUSTODY OF A CHILD

Data Elements

1. Court case number.

2. Court name. Check appropriate box to indicate the level of court.

3. Case name (name of child).

4. Name of Petitioner.

5. Check applicable box to indicate the basis of the petition.

6. Insert the name(s) of persons who have provided testimony to the court.

7. Name of child whose custody is at issue.

8. Check the applicable box to indicate the findings of the court.

9. Insert the supporting facts upon which the finding of the court is based.

10. Name of person who has physical custody of the child.

11. Address of person who has physical custody of the child.

12. Insert appropriate law enforcement agency that is being ordered to take physical custody
of the child.

13. Check box and insert the name of the appropriate law enforcement agency if the facts
warrant giving the officers the ability to enter private property to take physical custody of
the child.

14. Check box and insert the name of the appropriate law enforcement agency if the officers
are given the ability to forcibly enter private property at any hour to take physical custody
of the child.

15. Person or agency that the child should be placed with pending a hearing and final order in
the case.

16. Date and time of hearing.

17. Date order issued.

18. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

JANUARY 2014
Form DC-587 MOTION AND ORDER FOR EXPUNGEMENT Page: 1
AND DESTRUCTION OF JUVENILE RECORDS

Using This Form

1. Copies

a. Original – to court.

b. First copy – to appropriate office of the Commonwealth’s Attorney.

2. Prepared primarily by petitioner. Notice and order prepared by clerk and judge respectively.

3. Preparation details

This form is designed to assist those who wish to expunge juvenile court records. Notice
of the filing of the motion should be given to the Commonwealth’s Attorney.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-587 MOTION AND ORDER FOR EXPUNGEMENT Page: 2
AND DESTRUCTION OF JUVENILE RECORDS
MOTION AND ORDER FOR EXPUNGEMENT Case No. 1
.....................................................................
AND DESTRUCTION OF JUVENILE RECORDS
Commonwealth of Virginia VA. CODE § 16.1-306
2
.......................................................................................................................................... Juvenile and Domestic Relations District Court
3
...........................................................................................................................................................................................................................................
STREET ADDRESS OF COURT

As the person who was the subject of a delinquency or traffic proceeding in the above-entitled matter, with
disposition of the charge on 5
................................................................................................ , and:
DATE OF FINAL DISPOSITION OF CHARGE

[ ] having been found innocent thereof

6 OR

[ ] the proceedings having been otherwise dismissed

I move the court to expunge this matter and destroy all records pertaining to this charge. I further request the Court
provide notice of this motion to the attorney of the Commonwealth.
I further state that:
My date of birth is 7
...............................................................................
My Social Security Number is 8
..................................................................................
Specific charge(s) to be expunged: ....................................................................................................................................................................
Charge(s) Code Section(s) Court Case Number(s)

10
........................................................................ _____________________________________________________________ 11
DATE SIGNATURE OF PETITIONER

12
......................................................................................................... 13
........................................................................................................
ATTORNEY OF PETITIONER PRINT NAME OF PETITIONER

14
...........................................................................................................................................................................................................................................
ADDRESS/TELEPHONE NUMBER OF [ ] PETITIONER [ ] ATTORNEY FOR PETITIONER

NOTICE TO RESPONDENT COMMONWEALTH:

This motion was made pursuant to Va. Code § 16.1-306. If you wish to contest this Motion, written notice must be
filed in the clerk’s office by:
15
.................................................................................................... 16
for a hearing on ....................................................................................................
FILING DEADLINE HEARING DATE

17
........................................................................ 18
_____________________________________________________________
DATE [ ] CLERK [ ] DEPUTY CLERK

ORDER
[ ] This Court, having not been shown good cause why such records should not be destroyed, ORDERS that the
motion requesting the destruction of all records pertaining to this charge is hereby granted. The clerk shall send a
copy of this ORDER to all officers or agencies that are repositories of said records, and all such officers and
agencies shall comply with the ORDER in accordance with § 16.1-306.
[ ] After conduction a hearing on the petition, the Court ORDERS that the petition be denied.
20
........................................................................ 21
______________________________________________________________
DATE
19 JUDGE

FORM DC-587 REVISED 11/07

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-587 MOTION AND ORDER FOR EXPUNGEMENT Page: 3
AND DESTRUCTION OF JUVENILE RECORDS

Data Elements

1. Court case number.

2. Court name. Check appropriate box to indicate level of court.

3. Street address of court.

4. Case name (name of child).

5. Insert date of final disposition of the charge in the case identified immediately above.

6. Check applicable box to indicate basis of the motion.

7. Insert date of birth of petitioner.

8. Insert social security number of petitioner.

9. Insert the specific charge(s) to be expunged, related statutory references and court case numbers in
the columns provided. Any related detail(s) may be provided in the space allotted.

10. Date signed by the person filing the motion.

11. Signature of person filing the motion.

12. Name of the attorney representing the person filing the motion, if any.

13. Printed name of the person filing the motion.

14. Insert address and telephone number of person filing the motion or the attorney representing such
person. Check appropriate box immediately below.

15. Insert Commonwealth’s deadline for filing written notice of desire to contest the expungement
motion.

16. Insert hearing date.

17. Date of issuance of notice.

18. Signature of clerk or deputy clerk issuing notice.

19. Check appropriate box.

20. Date of entry of order.

21. Signature of judge.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2007
Form DC-588 NOTICE OF EXPUNGEMENT RIGHTS Form DC-588

Using This Form

This form may serve as notice of the rights of expungement, required to be provided at
the time of a juvenile’s disposition hearing pursuant to Virginia Code § 16.1-306(D). A similar
notice of rights may be found on the reverse of DC-511 PETITION.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
NOTICE OF RIGHTS UPON DISPOSITION OF YOUR CASE

PLEASE BE ADVISED OF THE FOLLOWING RIGHTS UNDER

VIRGINIA CODE § 16.1-306 REGARDING EXPUNGEMENT OF
COURT RECORDS.

The clerk of the juvenile and domestic relations district court shall, on January 2 of each year or
on a date designated by the court, destroy its files, papers and records, including electronic
records, connected with any proceeding concerning a juvenile in such court, if such juvenile has
attained the age of 19 years and five years have elapsed since the date of the last hearing in any
case of the juvenile which is subject to this section. However, if the juvenile was found guilty of
an offense for which the clerk is required by Virginia Code § 46.2-383 to furnish an abstract to
the Department of Motor Vehicles, the records shall be destroyed when the juvenile has attained
the age of 29. If the juvenile was found guilty of a delinquent act, which would be a felony if
committed by an adult, the records shall be retained.

However, in all files in which the court records concerning a juvenile contain a finding of guilty
of any offense ancillary to (i) a delinquent act that would be a felony if committed by an adult or
(ii) any offense for which the clerk is required by § 46.2-383 to furnish an abstract to the
Department of Motor Vehicles, the records of any such ancillary offense shall also be retained
for the time specified for the felony or the offense reported to the Department of Motor Vehicles
as specified above, and all such records shall be available for inspection as provided in § 16.1-
305.

A person who has been the subject of a delinquency or traffic proceeding and (i) has been found
innocent thereof or (ii) such proceeding was otherwise dismissed, may file a motion requesting
the destruction of all records pertaining to such charge. Notice of such motion shall be given to
the attorney for the Commonwealth. Unless good cause is shown why such records should not
be destroyed, the court shall grant the motion, and shall send copies of the order to all officers or
agencies that are repositories of such records, and all such officers and agencies shall comply
with the order.

Upon destruction of the records of a proceeding, the violation of law shall be treated as if it never
occurred. All index references shall be deleted and the court and law-enforcement officers and
agencies shall reply and the person may reply to any inquiry that no record exists with respect to
such person.

FORM DC-588 MASTER 07/14

Form DC-592 EMERGENCY CUSTODY ORDER – JUVENILE Form DC-592

Using This Form

1. Copies

a. Original – to court.

b. Second copy – to juvenile.

c. Additional copy – to community service board evaluator conducting evaluation.

2. Prepared by magistrate or judge. Judges may issue this order only pursuant to Virginia
Code § 16.1-345.4.

3. Attachments

a. Form DC-4000, ORDER FOR ALTERNATIVE TRANSPORTATION PROVIDER, only if it

is ordered that the juvenile is to be transported to the facility by an alternative
transportation provider.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
EMERGENCY CUSTODY ORDER – JUVENILE 1
Case No. ......................................................................................
Commonwealth of Virginia VA. CODE § 16.1-340, 16.1-345.4

[ ] Juvenile and Domestic Relations District Court

2
............................................................................................................................................ [ ] Circuit Court
3
........................................................................................................................................................................................................................................................................
NAME AND ADDRESS OF JUVENILE

4
........................................................................................................................................................................................................................................................................
NAME AND ADDRESS OF PARENT/GUARDIAN/LEGAL CUSTODIAN
TO ANY AUTHORIZED OFFICER OF: 9 COMPLETE DATA BELOW IF KNOWN
5
............................................................................................................................................
RACE SEX BORN HT. WGT. EYES HAIR
MO. DAY YR. FT. IN.
This emergency custody order is hereby issued
6 [ ] upon motion of the undersigned [7] upon a sworn petition SSN

8 [ ] and facts presented by

DL# STATE
........................................................................................................................................... ,
NAME TELEPHONE NUMBER
based upon probable cause to believe that the juvenile, pursuant to § 16.1-340,(i), because of mental illness, (a) presents a serious danger
to self or others to the extent that severe or irremediable injury is likely to result, as evidenced by recent acts or (b) threats OR is
experiencing a serious deterioration of the ability to care for self in a developmentally age-appropriate manner, as evidenced by
delusionary thinking or by a significant impairment of functioning in hydration, nutrition, self-protection, or self control, and (ii) the
juvenile is in need of compulsory treatment for a mental illness and is reasonably likely to benefit from the proposed treatment.

10 [ ] 10
The juvenile failed to appear for a hearing on .............................................. to review a mandatory outpatient treatment plan pursuant to
§ 16.1-345.4. DATE

THEREFORE, you are commanded to execute this order, take the juvenile into custody and
11 [ ] transport the juvenile to the location listed below for evaluation by a person designated by the community services board or
behavioral health authority who is skilled in the diagnosis and treatment of mental illness and who has completed a certification
program approved by the Department of Behavioral Health and Developmental Services in order to assess the need for
hospitalization or treatment.
12 [ ] transfer custody of the respondent to the alternative transportation provider, ........................................................................................................
DC-4000, ORDER FOR ALTERNATIVE TRANSPORTATION PROVIDER, is attached.
Custody of the juvenile may be transferred pursuant to § 16.1-340(E). The juvenile shall remain in custody until a temporary detention order
is issued, until the evaluator finds that the juvenile does not meet the criteria for detention, or until this emergency custody order expires. If
the undersigned judicial officer issues this order pursuant to § 16.1-340, then (1) the order is void if not executed within eight hours of the
time of issuance and (2) the order is valid for a period not to exceed eight hours from the time of execution. If the order becomes void for
lack of timely execution, pursuant to § 16.1-340(L), a law-enforcement officer must return the order to the office of the clerk of the issuing
court, or, if such office is not open, to any magistrate serving that court.
13
........................................................................................................................................................................................................................................................................
CURRENT LOCATION OF JUVENILE

14
........................................................................................................................................................................................................................................................................
NAME AND ADDRESS OF LOCATION FOR EVALUATION OR EXAMINATION

15 [ ] Transport the juvenile to the medical facility (specified below) to obtain the following:
16 [ ] emergency medical evaluation or treatment, before transporting the juvenile to the above specified location for evaluation.
17 [ ] a medical evaluation, before transporting the juvenile to a hospital at which the juvenile may be admitted for detention if a
physician at that hospital requires a medical evaluation of the juvenile prior to the admission.
18
........................................................................................................................................................................................................................................................................
NAME AND ADDRESS OF MEDICAL EVALUATION FACILITY

TO THE PERSON CONDUCTING THE MENTAL HEALTH EVALUATION:

Virginia Code § 16.1-340 requires that you evaluate the juvenile pursuant to this order. Upon completion of your evaluation, promptly report
the results of your evaluation to the appropriate judicial officer.
TO THE PERSON PROVIDING EMERGENCY MEDICAL EVALUATION OR TREATMENT:
Virginia Code § 16.1-340 requires that you conduct the medical evaluation or treatment immediately in accordance with state and federal law.
TO ANY HEALTH CARE PROVIDER as defined in Virginia Code § 32.1-127.1:03, or other provider rendering services to or is currently
evaluating the juvenile: Virginia Code § 16.1-337 requires you to disclose certain information upon request. (See Page Two,
AUTHORIZATION FOR DISCLOSURE AND USE OF HEALTH INFORMATION.)

19
......................................................................................................... 20
_____________________________________________________________
DATE AND TIME OF ISSUANCE [ ] MAGISTRATE [ ] JUDGE

FORM DC-592 (MASTER, PAGE ONE OF TWO) 07/14

Form DC-592 EMERGENCY CUSTODY ORDER – JUVENILE Form DC-592

Data Elements, page one

1. Insert court case number.

2. Insert court name. Check appropriate box.

3. Insert name and permanent address of juvenile.

4. Insert name and address of parent/guardian/legal custodian.

5. Insert the name of the officer’s law enforcement agency.

6. Check this box if this order is being issued on motion of the judicial officer signing the order.

7. Check this box if this order is being issued upon a sworn petition.

8. Check this box if this order is also being issued based upon facts presented by an individual,
and insert name and telephone number of that person.

9. Insert identifying information for the juvenile, if known.

10. Check this box if the order is being issued because the juvenile failed to appear for a hearing to
review a mandatory outpatient treatment plan, and insert date of hearing for which juvenile did
not appear.

11. Check this box if the juvenile will be transported for evaluation by a law enforcement officer.

12. Check this box if the juvenile will be transported for evaluation by an alternative transportation
provider. Insert name of alternative transportation provider. Attach form DC-4000, ORDER FOR
ALTERNATIVE TRANSPORTATION PROVIDER.

13. Insert current location of the juvenile.

14. Insert name and address of location where evaluation will occur.

15. Magistrate should check this box if the juvenile needs a medical evaluation.

16. Check box if evidence presented demonstrates that respondent needs an emergency medical
evaluation or treatment prior to admission to facility identified in Data Element No. 13.

17. Check box if a physician at the facility identified in Data Element No. 13 requires a pre-
admission medical evaluation.

18. Name and address of location where medical evaluation or treatment will occur.

19. Insert date and time when this order is issued.

20. Signature of judicial officer entering this order. Check box below signature line indicating title.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
1
Case No. ......................................................................................

EXECUTED by taking the juvenile into custody: Juvenile evaluation completed:

2
.............................................................................................................................. 6
..............................................................................................................................
DATE AND TIME DATE AND TIME

3
.............................................................................................................................. 7
..............................................................................................................................
OFFICER TAKING JUVENILE INTO CUSTODY NAME OF FACILITY

_______________________________________________________________ 4 8
by ___________________________________________________________
BADGE NO., AGENCY AND JURISDICTION

5
for ____________________________________________________________ 9
..............................................................................................................................
SHERIFF TITLE

AUTHORIZATION FOR DISCLOSURE AND USE OF HEALTH INFORMATION

Under Virginia Code § 16.1-337, any health care provider, as defined in Virginia Code § 32.1-127.1:03, or
other provider rendering services to a minor who is the subject of proceedings pursuant to the Psychiatric
Treatment of Minors Act (Act) must, upon request, disclose to a magistrate, the juvenile intake officer, the
court, the minor's attorney, the minor's guardian ad litem, the qualified evaluator performing the evaluation
required under §§ 16.1-338, 16.1-339, and 16.1-342, the community services board or its designee performing
the evaluation, preadmission screening, or monitoring duties under the Act, or a law-enforcement officer any
and all information that is necessary and appropriate to enable each of them to perform his duties under the Act.
These health care providers and other service providers must disclose to one another health records and
information where necessary to provide care and treatment to the minor and to monitor that care and treatment.
Health records disclosed to a law-enforcement officer must be limited to information necessary to protect the
officer, the minor, or the public from physical injury or to address the health care needs of the minor.
Information disclosed to a law-enforcement officer must not be used for any other purpose, disclosed to others,
or retained.
Any health care provider providing services to a minor who is the subject of proceedings pursuant to the
Psychiatric Treatment of Minors Act may notify the minor’s parent of information which is directly relevant to
such individual’s involvement with the minor’s health care, which may include the minor’s location and general
condition, in accordance with § 32.1-127.1:03(D)(34), unless the provider has actual knowledge that the parent
is currently prohibited by court order from contacting the minor.
Any health care provider disclosing records pursuant to this section will be immune from civil liability for any
harm resulting from the disclosure, including any liability under the federal Health Insurance Portability and
Accountability Act (42 U.S.C. § 1320d et seq.), as amended, unless the person or provider disclosing such
records intended the harm or acted in bad faith.

FORM DC-592 (MASTER, PAGE TWO OF TWO) 07/14

Form DC-592 EMERGENCY CUSTODY ORDER – JUVENILE Form DC-592

Data Elements, page two

1. Insert court case number.

2. Insert date and time juvenile taken into custody.

3. Signature of officer executing this order.

4. Insert badge number, agency and jurisdiction that employs the officer.

5. If executed by a deputy sheriff, print or type name of sheriff.

The following elements (Nos. 6-9) are completed on the original and third copies:

6. Insert date and time juvenile evaluation completed.

7. Insert location where evaluation was performed.

8. Insert name of person who performed evaluation.

9. Insert title of person who performed evaluation.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2014
Form DC-594 TEMPORARY DETENTION ORDER – JUDGE (JUVENILE) Page: 1

Using This Form

1. Copies

a. Original – to court.

b. First copy – to respondent.

c. Second copy – to institution (invoice copy).

d. Third copy – to institution (file copy).

2. Prepared by a judge. Data Element Nos. 19 and 20 are completed by the institution and
Data Element Nos. 21 through 25 are completed by the officer.

3. Attachments – First copy

a. Form DC-4000, ORDER FOR ALTERNATIVE TRANSPORTATION PROVIDER, if

applicable.

b. Form DC-592, EMERGENCY CUSTODY ORDER – JUVENILE.

c. Form DC-493, INVOLUNTARY MENTAL COMMITMENT PROCESS – written

explanation.

4. Preparation details

a. The copy of this Order marked “Respondent” must be provided to the juvenile.

b. Data Element No. 16 – the Order becomes void if not served within 24 hours after
issuance or such shorter time as set by the judge.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2010
Form DC-594 TEMPORARY DETENTION ORDER – JUDGE (JUVENILE) Page: 2

TEMPORARY DETENTION ORDER – JUDGE (JUVENILE) 1

Case No. ..........................................................
Commonwealth of Virginia Va. Code §§ 16.1-340.1, 16.1-345.4

[ ] Circuit Court
2
................................................................................................................................................ [ ] Juvenile and Domestic Relations District Court
3
...............................................................................................................................................................................................................................................................................
NAME AND ADDRESS OF JUVENILE

6
TO ANY AUTHORIZED OFFICER OF: ...................................................................................
Consideration having been given to the evidence, this temporary detention
order is hereby issued to detain the juvenile who failed to appear at COMPLETE DATA BELOW IF KNOWN
7
a hearing on ...................................................................... to review a mandatory RACE SEX BORN HT. WGT. EYES HAIR
DATE MO. DAY YR. FT. IN.
outpatient treatment plan pursuant to § 16.1-345.4.
SSN
THEREFORE, you are commanded to execute this order, take the
juvenile into custody and DL# STATE
5
8 [ ] transport the juvenile from the juvenile’s present location to
the location listed below,
9 [ ] transfer custody of the juvenile to the alternative transportation provider as designated on the attached form
DC-4000, ORDER FOR ALTERNATIVE TRANSPORTATION PROVIDER.
10
....................................................................................................................................................................................................................................................
CURRENT LOCATION OF JUVENILE

12 [ ] Prior to placement in the above temporary detention facility, transport the juvenile
13 [ ] for emergency medical evaluation or treatment
14 [ ] for medical evaluation or treatment as may be required by a physician at the temporary detention facility
15
to: ........................................................................................................................................................................................................................................................................
NAME AND ADDRESS OF FACILITY

In accordance with § 16.1-345.4, the hearing to review the mandatory outpatient treatment order shall be scheduled within
the same time frame provided for a commitment hearing under § 16.1-341. This order becomes void if not executed within:
[ ] 24 hours [ ] .................................................. hours after issuance. 16
TO ANY HEALTH CARE PROVIDER as defined in Virginia Code § 32.1-127.1:03, or other provider rendering
services to or is currently evaluating the juvenile: Virginia Code § 16.1-337 requires you to disclose certain information
upon request. (See Page Two, AUTHORIZATION FOR DISCLOSURE AND USE OF HEALTH INFORMATION.)
17
.......................................................................................... 18
______________________________________________________________
DATE AND TIME OF ISSUANCE JUDGE

19
Respondent discharged from institution on this day: .............................................. by 20
...................................................................................................
NAME AND TITLE

EXECUTED by delivering a copy of this Order to the juvenile on this day

21
..................................................................................................................... 22
.........................................................................................................................................
DATE AND TIME OF EXECUTION DATE AND TIME JUVENILE DELIVERED TO FACILITY

23
______________________________________________________________ 24
_______________________________________________________________
OFFICER TAKING JUVENILE INTO CUSTODY BADGE NO., AGENCY, AND JURISDICTION

25
for __________________________________________________________ SHERIFF

FORM DC-594 FRONT 07/10

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2010
Form DC-594 TEMPORARY DETENTION ORDER – JUDGE (JUVENILE) Page: 3

Data Elements, front

1. Court case number. 13. Check box if evidence presented

demonstrates that the juvenile needs an
2. Court jurisdiction. Check box emergency medical evaluation or
indicating type of court. treatment prior to admission to facility
identified in Data Element No. 15.
3. Full name and current address of the
juvenile. 14. Check box if physician at the facility
identified in Data Element No. 15
4. Name and address of parent/guardian/ requires pre-admission medical
legal custodian. evaluation.

5. Information describing the juvenile. 15. Name and address of facility where
Include only data which is known. medical evaluation or treatment will
Indicate social security number, if occur.
available.
16. Check appropriate box indicating time
6. Specify the primary law-enforcement period for when order becomes void if
agency and jurisdiction that should not executed. If less that 24 hours, enter
execute the temporary detention order the number in the appropriate blank.
and provide transportation, if applicable.
17. Date and time order was issued.
7. Check this box to detain a juvenile who
has failed to appear at a hearing to 18. Signature of judge issuing order.
review a mandatory outpatient treatment
plan pursuant to § 16.1-345.4. 19. For institution’s use only. Date and
time on which institution discharged the
8. Check this box if law enforcement is juvenile.
ordered to transport the juvenile to the
designated facility. 20. For institution’s use only. Name and
title of person who discharged the
9. Check this box if law enforcement is juvenile.
ordered to transfer custody of the
juvenile to the alternative transportation 21. Date and time of execution.
provider for transportation of the
juvenile to the designated facility. 22. Date and time the juvenile was delivered
Attach form DC-4000, ORDER FOR to the facility in Data Element No. 11.
ALTERNATIVE TRANSPORTATION
PROVIDER. 23. Signature of officer taking the juvenile
into custody.
10. Current location of the juvenile.
24. Badge number, agency and jurisdiction
11. Name and address of the facility to or officer.
which the juvenile will be committed.
25. Name of sheriff, if executed by deputy
12. Check box (and related Data Element sheriff.
No. 13 or No. 14) if the juvenile
requires preliminary medical evaluation.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2010
Form DC-594 TEMPORARY DETENTION ORDER – JUDGE (JUVENILE) Page: 4

AUTHORIZATION FOR DISCLOSURE AND USE OF HEALTH INFORMATION

Under Virginia Code § 16.1-337, any health care provider, as defined in Virginia Code § 32.1-127.1:03, or other
provider rendering services to a minor who is the subject of proceedings pursuant to the Psychiatric Treatment of
Minors Act (Act) must, upon request, disclose to a magistrate, the juvenile intake officer, the court, the minor's
attorney, the minor's guardian ad litem, the qualified evaluator performing the evaluation as required under §§ 16.1-
338, 16.1-339, and 16.1-342, the community services board or its designee performing the evaluation, preadmission
screening, or monitoring duties under the Act, or a law-enforcement officer any and all information that is necessary
and appropriate to enable each of them to perform his duties under the Act. These health care providers and other
service providers must disclose to one another health records and information where necessary to provide care and
treatment to the minor and to monitor that care and treatment. Health records disclosed to a law-enforcement officer
must be limited to information necessary to protect the officer, the minor, or the public from physical injury or to
address the health care needs of the minor. Information disclosed to a law-enforcement officer must not be used for any
other purpose, disclosed to others, or retained.
Any health care provider providing services to a minor who is the subject of proceedings pursuant to the Psychiatric
Treatment of Minors Act may notify the minor’s parent of information which is directly relevant to such individual’s
involvement with the minor’s health care, which may include the minor’s location and general condition, in accordance
with § 32.1-127.1:03(D)(34), unless the provider has actual knowledge that the parent is currently prohibited by court
order from contacting the minor.
Any health care provider disclosing records pursuant to this section will be immune from civil liability for any harm
resulting from the disclosure, including any liability under the federal Health Insurance Portability and Accountability
Act (42 U.S.C. § 1320d et seq.), as amended, unless the person or provider disclosing such records intended the harm
or acted in bad faith.

FORM DC-594 REVERSE 07/10

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2010
Form DC-597 ORDER FOR INPATIENT TREATMENT – Page: 1
ADMISSION BY PARENTAL CONSENT

Using This Form

1. Copies

a. Original – to court.

b. First copy – to juvenile.

c. Second copy – to parent(s) of juvenile.

d. Third copy – to hospital.

e. Additional copies as needed.

2. Prepared for and signed by judge or special justice.

3. Attachments – none.

4. Preparation details –

a. Use this form for orders for admission of objecting juvenile by parental consent
pursuant to Va. Code § 16.1-339. For orders for involuntary commitment for
inpatient treatment pursuant to Va. Code § 16.1-345, use form DC-598, ORDER
FOR INVOLUNTARY COMMITMENT FOR INPATIENT TREATMENT – JUVENILE. For
orders for involuntary admission to mandatory outpatient treatment pursuant to
Va. Code § 16.1-345.2, use form DC-599, ORDER FOR INVOLUNTARY ADMISSION
TO MANDATORY OUTPATIENT TREATMENT – JUVENILE.

b. On page one, Data Element Nos. 6, 8 and 9 are mutually exclusive. Only one of
them should be checked.

c. If Data Element No. 9 is checked on page one, check box for Data Element No.
11, and then check other applicable boxes.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2010
Form DC-598 ORDER FOR INPATIENT TREATMENT – Page: 2
ADMISSION BY PARENTAL CONSENT
ORDER FOR INPATIENT TREATMENT – 1
Case No. ........................................................................
ADMISSION BY PARENTAL CONSENT
Commonwealth of Virginia Va. Code § 16.1-339
2
..................................................................................................................... Juvenile and Domestic Relations District Court
In re: 3
..................................................................................................................................... , a juvenile hospitalized at
4
...............................................................................................................................................................................................................................................................................
NAME OF FACILITY

Present: [ ] Child ................................................................................................. [ ] Mother ........................................................................................................

[ ] in person [ ] by audio/video or telephone [ ] in person [ ] by audio/video or telephone
[ ] Attorney for Child ....................................................................... [ ] Father ..........................................................................................................
[ ] in person [ ] by audio/video or telephone
[ ] Guardian ad litem ........................................................................ [ ] Attending psychiatrist ..........................................................................
5 [ ] in person [ ] by audio/video or telephone
[ ] CSB ........................................................................................................................................................................................................................................
NAME OF CSB EMPLOYEE/DESIGNEE NAME OF CSB AND TELEPHONE NUMBER
[ ] in person [ ] by audio/video or telephone
[ ] Qualified Evaluator ..........................................................................................................................................................................................................
[ ] in person [ ] by audio/video or telephone
[ ] Other ......................................................................................................................................................................................................................................
NAME ADDRESS RELATIONSHIP/TITLE

The above-named juvenile has been brought before this Court upon the filing of a written petition. Proper notice has been given to
all proper and necessary parties, and the parties have been informed by this Court of the contents of the petition filed in this Court.
The Court has appointed a guardian ad litem for the juvenile and counsel to represent the juvenile, unless it has been determined that
the juvenile has retained counsel, and has received a written report from the qualified evaluator which included a written finding on
whether the criteria for inpatient treatment have been met. A copy of the evaluator’s report was provided to the juvenile’s guardian ad
litem and to the juvenile’s counsel. All provisions of the Juvenile and Domestic Relations District Court law, and amendments
thereto, have been duly complied with in assuming jurisdiction of the juvenile.
Having considered all relevant material evidence, the Court finds that the juvenile is within the jurisdiction of this Court and the
Juvenile and Domestic Relations District Court law, and
6 A. [ ] the juvenile does not meet the criteria for admission. Therefore, the Court ORDERS that the above-named facility where the
juvenile is hospitalized release the juvenile, pursuant to § 16.1-339(C)(1),
[ ] to the custody of the juvenile’s parent(s) who consented to the hospitalization. OR
7
[ ] in accordance with the terms and conditions of a valid court order of custody affecting the juvenile.
8 B. [ ] there is insufficient information to permit an informed determination as to whether the juvenile meets the criteria for
admission. Therefore, the Court ORDERS that the following involuntary commitment hearing shall be held:
.............................................................................................................................................................................................................................................................
DATE, TIME AND PLACE
and that the juvenile may be detained in the above-named hospital for up to 96 hours from entry of this Order pending the
involuntary commitment hearing.
9 C. [ ] the juvenile meets the following criteria for admission:
1. Because of mental illness, the juvenile 11
10 [ ] presents a serious danger to [ ] self [ ] others to the extent that severe or irremediable injury is likely to result, as
evidenced by recent acts or threats, OR

12 [ ] is experiencing a serious deterioration of ability to care for self in a developmentally age-appropriate manner, as
evidenced by 15
13 [ ] delusionary thinking, or
14 [ ] a significant impairment of functioning in [ ] hydration [ ] nutrition [ ] self-protection [ ] self-control
AND
FORM DC-597 (MASTER, PAGE ONE OF TWO) 07/10

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2010
Form DC-597 ORDER FOR INPATIENT TREATMENT – Page: 3
ADMISSION BY PARENTAL CONSENT

Data Elements, page one of two

1. Court case number.

2. Court name.

3. Name of juvenile.

4. Name of facility seeking this order.

5. Check applicable boxes indicating who attended the hearing and how they appeared. Insert
names of people and other information where appropriate.

6. Check this box if the juvenile does not meet admission criteria and is to be released. See Using
This Form, 4(b).

7. If Data Element No. 6 is checked, check applicable box.

8. Check this box if an involuntary commitment hearing is to be held and insert the date, time and
place for the hearing. See Using This Form, 4(b).

9. Check this box if the juvenile meets the admission criteria. See Using This Form, 4(b) and (c).

10. If Data Element No. 9 is checked and this criterion is applicable, check this box and complete
Data Element No. 11.

11. If Data Element No. 10 is checked, then check either “self” or “others” or both “self” and
“others” as applicable.

12. If Data Element No. 9 is checked and this criterion is applicable, check this box and complete
Data Element No. 13 or 14.

13. If Data Element No. 12 is checked, check this box if applicable.

14. If Data Element No. 12 is checked, check this box if applicable and complete Data Element No. 15.

15. If Data Element No. 14 is checked, check the applicable box(es).

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2010
Form DC-598 ORDER FOR INPATIENT TREATMENT – Page: 4
ADMISSION BY PARENTAL CONSENT

1
Case No. ......................................................................

2. The juvenile is in need of inpatient treatment for a mental illness and is reasonably likely to benefit from the proposed
treatment, AND

3. Inpatient treatment is the least restrictive alternative that meets the juvenile’s needs.

Therefore, the Court ORDERS that the juvenile may be hospitalized for up to 90 days on the basis of the consent of the parent(s)
of the juvenile.
2[ ] The juvenile, who has been hospitalized while properly detained by a juvenile and domestic relations district court or circuit
court, shall be returned to the detention home, shelter care or other facility approved by the Department of Juvenile Justice by
the sheriff serving the jurisdiction where the minor was detained within 24 hours following completion of this period of
inpatient treatment unless the court having jurisdiction over the case orders that the juvenile be released from custody.
3[ ] The court further ORDERS pursuant to § 16.1-345 that transportation of the person to the facility shall be provided by
4[ ] the Sheriff of ..................................................................................................

5[ ] the alternative transportation provider as designated on the attached form DC-4000, ORDER FOR ALTERNATIVE
TRANSPORTATION PROVIDER.

6
.......................................................................................... 7
_______________________________________________________________________
DATE [ ] JUDGE [ ] SPECIAL JUSTICE

AUTHORIZATION FOR DISCLOSURE AND USE OF HEALTH INFORMATION

Any health care provider providing services to a minor who is the subject of proceedings pursuant to the Psychiatric Treatment of
Minors Act may notify the minor’s parent of information which is directly relevant to such individual’s involvement with the minor’s
health care, which may include the minor’s location and general condition, in accordance with § 32.1-127.1:03(D)(34), unless the
provider has actual knowledge that the parent is currently prohibited by court order from contacting the minor.

Any health care provider disclosing records pursuant to this section will be immune from civil liability for any harm resulting from the
disclosure, including any liability under the federal Health Insurance Portability and Accountability Act (42 U.S.C. § 1320d et seq.),
as amended, unless the person or provider disclosing such records intended the harm or acted in bad faith.

FORM DC-597 (MASTER, PAGE TWO OF TWO) 07/10

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2010
Form DC-597 ORDER FOR INPATIENT TREATMENT – Page: 5
ADMISSION BY PARENTAL CONSENT

Data Elements, page two of two

1. Court case number.

2. Check this box if the juvenile was detained prior to hospitalization and the juvenile is to be
returned to the detention home, shelter care or other facility approved by the Department of
Juvenile Justice after completion of inpatient treatment.

3. Check this box if transportation of the juvenile to the facility is necessary.

4. Check this box if transportation is to be provided by the sheriff, and insert name of jurisdiction.

5. Check this box if transportation to the facility is to be provided by an alternative transportation

provider. Attach form DC-4000, ORDER FOR ALTERNATIVE TRANSPORTATION PROVIDER.

6. Date of signing of order.

7. Signature of judge or special justice. Check the applicable box.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2010
Form DC-598 ORDER FOR INVOLUNTARY COMMITMENT Form DC-598
FOR INPATIENT TREATMENT – JUVENILE

Using This Form

1. Copies

a. Original – to court.

b. First copy – to minor.

c. Second copy – to inpatient care provider.

d. Additional copies as needed.

2. Prepared for and signed by judge or special justice.

3. Attachments – Form DC-4000, ORDER FOR ALTERNATIVE TRANSPORTATION PROVIDER, if

applicable.

4. Preparation details –

a. Use this form for involuntary commitment of a minor for inpatient treatment pursuant to
Virginia Code § 16.1-345. For orders for admission of objecting minors by parental
consent pursuant to Va. Code § 16.1-339, use Form DC-597, ORDER FOR INPATIENT
TREATMENT – ADMISSION BY PARENTAL CONSENT. For orders for involuntary
admission to mandatory outpatient treatment pursuant to Va. Code § 16.1-345.2, use form
DC-599, ORDER FOR INVOLUNTARY ADMISSION TO MANDATORY OUTPATIENT
TREATMENT – JUVENILE.

b. Data Element Nos. 7 and 10 on page one are mutually exclusive. Only one of them
should be checked.

c. If Data Element No. 10 on page one is checked, then complete the following portions to
document the court’s findings:

• One of these combinations:

− Data Element Nos. 11 and 12, or
− Data Element Nos. 13 and 14, or
− Data Element Nos. 13, 15, and 16,

and

• One of these choices:

− Data Element Nos. 17 and 18 on page 2, or
− Data Element No. 19 on page 2.

d. All orders must be signed even if there is no involuntary commitment.

e. This form should also be used if a court finds that a juvenile who is 14 years of age or
older is capable of consenting to voluntary admission, and that the juvenile and the
juvenile’s parent have consented to make a joint application for voluntary admission for
inpatient treatment pursuant to Va. Code § 16.1-338.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2010
ORDER FOR INVOLUNTARY COMMITMENT FOR
INPATIENT TREATMENT – JUVENILE 1
Case No. ............................................................................................
Commonwealth of Virginia VA. CODE § 16.1-345

In re: 3
............................................................................................................................................................................................................................................... , a Juvenile
Present: [ ] Child ...................................................................................................... [ ] Mother .....................................................................................................
[ ] in person [ ] by audio/video or telephone [ ] in person [ ] by audio/video or telephone

[ ] Attorney for Child ............................................................................ [ ] Father .......................................................................................................

[ ] in person [ ] by audio/video or telephone

[ ] Guardian ad litem ............................................................................. [ ] Attending psychiatrist .......................................................................

[ ] in person [ ] by audio/video or telephone
4
[ ] CSB ..........................................................................................................................................................................................................................................
NAME OF CSB EMPLOYEE/DESIGNEE NAME OF CSB AND TELEPHONE NUMBER
[ ] in person [ ] by audio/video or telephone

[ ] Qualified Evaluator ...........................................................................................................................................................................................................

[ ] in person [ ] by audio/video or telephone

[ ] Other ......................................................................................................................................................................................................................................
NAME ADDRESS RELATIONSHIP/TITLE

The above-named minor has been brought before this Court upon the filing of a written petition. Proper notice has been given to all
proper and necessary parties, and the parties have been informed by this Court of the contents of the petition filed in this Court. The
Court has appointed a guardian ad litem for the minor at least 24 hours before the hearing.
[ ] The Court has appointed an attorney to represent the minor at least 24 hours before the hearing, OR
5
[ ] The minor is represented by retained counsel.
6[ ] The minor is placed in detention or shelter care in another case and notice prior to the hearing on this petition has been given to
the attorney for the juvenile in the other case, the attorney for the Commonwealth in the jurisdiction giving rise to the
detention, and the court having jurisdiction over the juvenile in detention or shelter care.
At least 24 hours before the scheduled hearing, the Court received from the qualified evaluator a written report which includes the
evaluator’s opinion as to whether the criteria for involuntary commitment have been met. A copy of the evaluator’s report was provided
to the minor’s guardian ad litem and to the minor’s counsel. Prior to the hearing, the court received the preadmission screening report
from the community services board. All provisions of the Juvenile and Domestic Relations District Court law, and amendments thereto,
have been duly complied with in assuming jurisdiction of the minor.
7[ ] As the juvenile is 14 years of age or older, the juvenile was informed at the commencement of the hearing of the juvenile’s
right to be voluntarily admitted for inpatient treatment as provided for in § 16.1-338, and the juvenile was afforded an
opportunity for voluntary admission, provided that the juvenile’s parent consents to such voluntary admission.
8 [ ] The Court finds that the juvenile is capable of consenting to voluntary admission.
Based upon the consent of the juvenile and of the juvenile’s parent to make a joint application for voluntary admission of
the juvenile for inpatient treatment pursuant to § 16.1-338, the petition is hereby dismissed.
Having reviewed the petition, considered the recommendations of the guardian ad litem, observed the minor, and considered the
recommendations of any treating or examining physician or psychologist licensed in Virginia, if available, any past actions of the minor,
any past mental health treatment of the minor, any qualified evaluator’s report, any medical records available, the preadmission
screening report, and any other evidence that was admitted, the Court finds that the minor is within the jurisdiction of this Court and the
Juvenile and Domestic Relations District Court law, and

9 A. [ ] the minor does not meet the criteria for involuntary commitment. Therefore, the Court ORDERS the release of the minor.
10 B. [ ] there is clear and convincing evidence that the minor meets the following criteria:
1. Because of mental illness, the minor 12
11 [ ] presents a serious danger to [ ] self [ ] others to the extent that severe or irremediable injury is likely to result, as
evidenced by recent acts or threats, OR
13 [ ] is experiencing a serious deterioration of ability to care for self in a developmentally age-appropriate manner, as
evidenced by 16
14 [ ] delusionary thinking, or
15 [ ] a significant impairment of functioning in [ ] hydration [ ] nutrition [ ] self-protection [ ] self-control
AND
FORM DC-598 (MASTER, PAGE ONE OF THREE) 11/10
Form DC-598 ORDER FOR INVOLUNTARY COMMITMENT Form DC-598
FOR INPATIENT TREATMENT – JUVENILE

Data Elements, page one

1. Court case number.

2. Court name. Check type of court.

3. Name of minor.

4. Check applicable boxes indicating who attended the hearing and how they appeared.
Insert names of people and other information where appropriate.

5. Check the applicable boxes regarding court-appointed or retained counsel and guardian
ad litem.

6. Check this box to indicate that appropriate notice has been provided as required when a
minor is in detention or shelter care.

7. Check this box if the minor is 14 years of age or older.

8. Check this box if the court finds that the minor is capable of consenting to voluntary
admission.

9. Check this box if the minor does not meet the criteria for involuntary commitment and is
to be released. See Using This Form, 4.b.

10. Check this box if the criteria for involuntary commitment for inpatient treatment are met.
See Using This Form, 4.b.

11. If Data Element No. 10 is checked and this criterion is applicable, check this box and
complete Data Element No. 12.

12. If Data Element No. 11 is checked, check either “self” or “others” or both “self” and
“others” as applicable.

13. If Data Element No. 10 is checked and this criterion is applicable, check this box and
complete Data Element No. 14 or 15.

14. If Data Element No. 13 is checked, check this box if applicable.

15. If Data Element No. 13 is checked, check this box if applicable, and complete Data
Element No. 16.

16. If Data Element No. 15 is checked, check the applicable box(es).

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2010
1
Case No. ............................................................................................

2. The minor is in need of compulsory treatment for a mental illness and is reasonably likely to benefit from the proposed
treatment, AND

17 [ ] Inpatient treatment is the least restrictive alternative that meets the minor’s needs and the parent(s) with whom the
minor resides:
[ ] are willing to approve the inpatient treatment, or
18 [ ] are not willing to approve the inpatient treatment, and such treatment is necessary to protect the minor’s life,
health, safety or normal development.
OR
19 [ ] The minor is placed in detention or shelter care and inpatient treatment is the least restrictive alternative that meets the
minor’s need for compulsory treatment of a mental illness.

Therefore, the court ORDERS the involuntary commitment of the minor for inpatient treatment for a period not to exceed 90 days, to
this mental health facility:
20
...................................................................................................................................................................................................................................................................................
NAME AND ADDRESS

21[ ] and the Court further finding that the best interest of the minor so requires, the parent(s) of the minor are directed to comply with
the following reasonable conditions relating to the minor’s treatment.
..........................................................................................................................................................................................................................................................................

22[ ] The court further orders pursuant to § 16.1-345 that transportation of the minor to the facility shall be provided by

23[ ] the Sheriff of ...................................................................................................

24[ ] the alternative transportation provided as designated on the attached form DC-4000, ORDER FOR ALTERNATIVE
TRANSPORTATION PROVIDER.
Transportation of the minor to the facility shall commence no later than six hours after the sheriff or alternative transportation
provider is notified of this order.

25[ ] The minor, who has been hospitalized while properly detained by a juvenile and domestic relations district court or circuit court,
shall be returned to the detention home, shelter care or other facility approved by the Department of Juvenile Justice by the sheriff
serving the jurisdiction where the minor was detained within 24 hours following completion of this period of inpatient treatment
unless the court having jurisdiction over the case orders that the juvenile be released from custody.

26
.......................................................................................... 27
________________________________________________________________
DATE [ ] JUDGE [ ] SPECIAL JUSTICE

FORM DC-598 (MASTER, PAGE TWO OF THREE) 11/10

Form DC-598 ORDER FOR INVOLUNTARY COMMITMENT Form DC-598
FOR INPATIENT TREATMENT – JUVENILE

Data Elements, page two

1. Court case number.

17. If Data Element No. 10 is checked, check if applicable and complete Data Element No. 18.

18. Check applicable box.

19. Check this box, if applicable, if the minor is in detention or shelter care.

20. If minor meets criteria for involuntary commitment for inpatient treatment, insert name
and address of facility where treatment is to be provided.

21. Check this box if parents are required to comply with conditions relating to the minor’s
treatment and describe the conditions.

22. Check this box if transportation of the minor to the facility is necessary.

23. Check this box if transportation is to be provided by the Sheriff, and insert name of the
jurisdiction.

24. Check this box if transportation is to be provided by an alternative transportation

provider. Attach form DC-4000, ORDER FOR ALTERNATIVE TRANSPORTATION PROVIDER.

25. Check this box if the minor was detained prior to hospitalization and the minor is to be
returned to the detention home, shelter care or other facility approved by the Department
of Juvenile Justice after completion of inpatient treatment.

26. Date of signing of order.

27. Signature of judge or special justice. Check appropriate title box.

DISTRICT COURT MANUAL FORMS VOLUME

DECEMBER 2010
AUTHORIZATION FOR DISCLOSURE AND USE OF HEALTH INFORMATION
Under Virginia Code § 16.1-337, any health care provider, as defined in Virginia Code § 32.1-127.1:03, or
other provider rendering services to a minor who is the subject of proceedings pursuant to the Psychiatric
Treatment of Minors Act (Act) must, upon request, disclose to a magistrate, the juvenile intake officer, the
court, the minor's attorney, the minor's guardian ad litem, the qualified evaluator performing the evaluation as
required under §§ 16.1-338, 16.1-339, and 16.1-342, the community services board or it’s designee
performing the evaluation, preadmission screening, or monitoring duties under the Act, or a law-enforcement
officer any and all information that is necessary and appropriate to enable each of them to perform his duties
under the Act. These health care providers and other service providers must disclose to one another health
records and information where necessary to provide care and treatment to the minor and to monitor that care
and treatment. Health records disclosed to a law-enforcement officer must be limited to information necessary
to protect the officer, the minor, or the public from physical injury or to address the health care needs of the
minor. Information disclosed to a law-enforcement officer must not be used for any other purpose, disclosed
to others, or retained.
Any health care provider providing services to a minor who is the subject of proceedings pursuant to the
Psychiatric Treatment of Minors Act may notify the minor’s parent of information which is directly relevant
to such individual’s involvement with the minor’s health care, which may include the minor’s location and
general condition, in accordance with § 32.1-127.1:03(D)(34), unless the provider has actual knowledge that
the parent is currently prohibited by court order from contacting the minor.
Any health care provider disclosing records pursuant to this section will be immune from civil liability for
any harm resulting from the disclosure, including any liability under the federal Health Insurance Portability
and Accountability Act (42 U.S.C. § 1320d et seq.), as amended, unless the person or provider disclosing
such records intended the harm or acted in bad faith.

FROM DC-598 (MASTER, PAGE THREE OF THREE) 07/10

Form DC-599 ORDER FOR INVOLUNTARY ADMISSION TO Page: 1
MANDATORY OUTPATIENT TREATMENT – JUVENILE

Using This Form

1. Copies

a. Original – to court.

b. First copy – to minor.

c. Second copy – to inpatient care provider.

d. Additional copies as needed.

2. Prepared for and signed by judge or special justice.

3. Attachments – Form DC-4000, ORDER FOR ALTERNATIVE TRANSPORTATION PROVIDER, if

applicable.

4. Preparation details –

a. Use this form for involuntary admission of a minor to mandatory outpatient treatment
pursuant to Va. Code § 16.1-345.2. For orders for admission of objecting minors by
parental consent pursuant to Va. Code § 16.1-339, use Form DC-597, ORDER FOR
INPATIENT TREATMENT – ADMISSION BY PARENTAL CONSENT. For orders for involuntary
commitment of a minor for inpatient treatment pursuant to Va. Code § 16.1-345, use
form DC-598, ORDER FOR INVOLUNTARY COMMITMENT FOR INPATIENT TREATMENT –
JUVENILE.

b. Data Element Nos. 7 and 8 on front side are mutually exclusive. Only one of them
should be checked.

c. If Data Element No. 8 on front side is checked, then complete the following portions to
document the court’s findings:

• One of these combinations:

− Data Element Nos. 9 and 10, or
− Data Element Nos. 11 and 12, or
− Data Element Nos. 11, 13, and 14.

d. All orders must be signed even if there is no involuntary commitment.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2010
Form DC-599 ORDER FOR INVOLUNTARY ADMISSION TO Page: 2
MANDATORY OUTPATIENT TREATMENT – JUVENILE
ORDER FOR INVOLUNTARY ADMISSION TO Case No. 1
........................................................................................
MANDATORY OUTPATIENT TREATMENT – JUVENILE
Commonwealth of Virginia VA. CODE §§ 16.1-345, 16.1-345.2
[ ] Circuit Court
2
......................................................................................................................................................... [ ] Juvenile and Domestic Relations District Court
3
In re: ............................................................................................................................................................................................................................................. , a Juvenile

Present: [ ] Child .................................................................................................. [ ] Mother .............................................................................................................

[ ] in person [ ] by audio/video or telephone [ ] in person [ ] by audio/video or telephone

[ ] Attorney for Child ....................................................................... [ ] Father ...............................................................................................................

[ ] in person [ ] by audio/video or telephone

[ ] Guardian ad litem ........................................................................ [ ] Attending psychiatrist ...............................................................................

[ ] in person [ ] by audio/video or telephone
4 [ ] CSB ...........................................................................................................................................................................................................................................
NAME OF CSB EMPLOYEE/DESIGNEE NAME OF CSB AND TELEPHONE NUMBER
[ ] in person [ ] by audio/video or telephone

[ ] Qualified Evaluator .............................................................................................................................................................................................................

[ ] in person [ ] by audio/video or telephone

The above-named minor has been brought before this Court upon the filing of a written petition. Proper notice has been given to
all proper and necessary parties, and the parties have been informed by this Court of the contents of the petition filed in this Court. The
Court has appointed a guardian ad litem for the minor at least 24 hours before the hearing.
[ ] The Court has appointed an attorney to represent the minor at least 24 hours before the hearing, OR
5
[ ] The minor is represented by retained counsel.
6 [ ] The minor is placed in detention or shelter care in another case and notice prior to the hearing on this petition has been given
to the attorney for the juvenile in the other case, the attorney for the Commonwealth in the jurisdiction giving rise to the
detention, and the court having jurisdiction over the juvenile in detention or shelter care.
At least 24 hours before the scheduled hearing, the Court received from the qualified evaluator a written report which includes the
evaluator’s opinion as to whether the criteria for involuntary commitment have been met. A copy of the evaluator’s report was
provided to the minor’s guardian ad litem and to the minor’s counsel. Prior to the hearing, the Court received the preadmission
screening report from the community services board. All provisions of the Juvenile and Domestic Relations District Court law, and
amendments thereto, have been duly complied with in assuming jurisdiction of the minor.
Having reviewed the petition, considered the recommendations of the guardian ad litem, observed the minor, and considered the
recommendations of any treating or examining physician or psychologist licensed in Virginia, if available, any past actions of the
minor, any past mental health treatment of the minor, any evaluation of the minor, any medical records, if available, the preadmission
screening report, and any other relevant evidence that was admitted, the Court finds that the minor is within the jurisdiction of this
Court and the Juvenile and Domestic Relations District Court law, and
7 A. [ ] the minor does not meet the criteria for involuntary commitment. Therefore, the Court ORDERS the release of the minor.
8 B. [ ] there is clear and convincing evidence that the minor meets the following criteria:
1. Because of mental illness, the minor 10
9 [ ] presents a serious danger to [ ] self [ ] others to the extent that severe or irremediable injury is likely to result as
evidenced by recent acts or threats, OR
11 [ ] is experiencing a serious deterioration of ability to care for self in a developmentally age-appropriate manner, as
evidenced by 14
12 [ ] delusionary thinking, or
13 [ ] a significant impairment of functioning in [ ] hydration [ ] nutrition [ ] self-protection [ ] self-control
AND
2. The minor is in need of compulsory treatment for a mental illness and is reasonably likely to benefit from the proposed
treatment, AND
3. Less restrictive alternatives to involuntary inpatient treatment that would offer an opportunity for improvement of the
juvenile’s condition have been investigated and are determined to be appropriate, AND
FORM DC-599 (MASTER, PAGE ONE OF THREE) 07/10

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2010
Form DC-599 ORDER FOR INVOLUNTARY ADMISSION TO Page: 3
MANDATORY OUTPATIENT TREATMENT – JUVENILE

Data Elements, page one

1. Court case number.

2. Court name. Check type of court.

3. Name of minor.

4. Check applicable boxes indicating who attending the hearing and how they appeared.
Insert names of people and other information where appropriate.

5. Check the applicable box regarding court-appointed or retained counsel.

6. Check this box to indicate that appropriate notice has been provided as required when a
minor is in detention or shelter care.

7. Check this box if the minor does not meet the criteria for involuntary commitment and is
to be released. See Using This Form, 4.b.

8. Check this box if the criteria for involuntary admission to mandatory outpatient treatment
are met. See Using This Form, 4.b.

9. If Data Element No. 8 is checked and this criterion is applicable, check this box and
complete Data Element No. 10.

10. If Data Element No. 9 is checked, check either “self” or “others” or both “self” and
“others” as applicable.

11. If Data Element No. 8 is checked and this criterion is applicable, check this box and
complete Data Element No. 12 or 13.

12. If Data Element No. 11 is checked, check this box if applicable.

13. If Data Element No. 11 is checked, check this box if applicable, and complete Data
Element No. 14.

14. If Data Element No. 13 is checked, check the applicable box(es).

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2010
Form DC-599 ORDER FOR INVOLUNTARY ADMISSION TO Page: 4
MANDATORY OUTPATIENT TREATMENT – JUVENILE
Case No. 1
........................................................................................

4. The juvenile, if 14 years of age or older, and the parent(s) of the juvenile
[ ] have sufficient capacity to understand the stipulations of the juvenile’s treatment,
[ ] have expressed an interest in the juvenile’s living in the community and have agreed to abide by the juvenile’s treatment
15 plan, and
[ ] are deemed to have the capacity to comply with the treatment plan and understand and adhere to conditions and
requirements of the treatment and services, AND

5. The ordered treatment can be delivered on an outpatient basis by the community services board or a designated provider as
the services are available in the community and providers of the services have agreed to deliver the services.

Therefore, the court ORDERS that the juvenile be involuntarily admitted to mandatory outpatient treatment for a period not to exceed
90 days, as set forth in the initial mandatory outpatient treatment plan attached and incorporated herein:

16 [ ] with modification(s) ............................................................................................................................................................................................................................

17 [ ] without modification,

18 [ ] and the Court further finding that the best interest of the minor so requires, the parent(s) of the minor are directed to comply with
the following reasonable conditions relating to the minor’s treatment:
......................................................................................................................................................................................................................................................................

It is further ordered that the community services board of the area in which the minor resides, namely
19
................................................................................................................................................ shall file a comprehensive mandatory outpatient treatment
CITY OR COUNTY WHERE MINOR RESIDES

plan with the Juvenile and Domestic Relations District Court of the same jurisdiction, and shall monitor the implementation of the
mandatory outpatient treatment plan and report any material noncompliance to the court.

20
......................................................................................................... 21
______________________________________________________________
DATE [ ] JUDGE [ ] SPECIAL JUSTICE

FORM DC-599 (MASTER, PAGE TWO OF THREE) 07/10

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2010
Form DC-599 ORDER FOR INVOLUNTARY ADMISSION TO Page: 5
MANDATORY OUTPATIENT TREATMENT – JUVENILE

Data Elements, page two

1. Court case number.

15. Check the appropriate boxes.

16. Check this box if applicable, and enter the modification(s) to the initial mandatory
outpatient treatment plan.

17. Check this box if there are no modifications to the plan.

18. Check this box if minor’s parent(s) are required to comply with any conditions relating to
the minor’s treatment and describe the conditions.

19. Enter the name of the city or county in which the minor resides.

20. Date of signing of order.

21. Signature of judge or special justice. Check appropriate title box.

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2010
Form DC-599 ORDER FOR INVOLUNTARY ADMISSION TO Page: 6
MANDATORY OUTPATIENT TREATMENT – JUVENILE

AUTHORIZATION FOR DISCLOSURE AND USE OF HEALTH INFORMATION

Any health care provider providing services to a minor who is the subject of proceedings pursuant to the
Psychiatric Treatment of Minors Act may notify the minor’s parent of information which is directly
relevant to such individual’s involvement with the minor’s health care, which may include the minor’s
location and general condition, in accordance with § 32.1-127.1:03(D)(34), unless the provider has actual
knowledge that the parent is currently prohibited by court order from contacting the minor.

Any health care provider disclosing records pursuant to this section will be immune from civil liability for
any harm resulting from the disclosure, including any liability under the federal Health Insurance
Portability and Accountability Act (42 U.S.C. § 1320d et seq.), as amended, unless the person or provider
disclosing such records intended the harm or acted in bad faith.

FORM DC-599 (MASTER, PAGE THREE OF THREE) 07/10

DISTRICT COURT MANUAL FORMS VOLUME

JULY 2010

Rodney Brown Abuse Court Documents
No ratings yet
Rodney Brown Abuse Court Documents
4 pages
Affidavit (Uniform Child Custody Jurisdiction and Enforcement Act) Inst
No ratings yet
Affidavit (Uniform Child Custody Jurisdiction and Enforcement Act) Inst
5 pages
Resume Template
No ratings yet
Resume Template
1 page
Caregiver
No ratings yet
Caregiver
3 pages
MC 416
No ratings yet
MC 416
2 pages
Valid Protection Order Signed by Judge
No ratings yet
Valid Protection Order Signed by Judge
3 pages
20160130161252
No ratings yet
20160130161252
27 pages
0651 1
No ratings yet
0651 1
11 pages
Fill-In
No ratings yet
Fill-In
2 pages
FL Rfo Packet
No ratings yet
FL Rfo Packet
15 pages
Waiver of Parental Notice Handbook
No ratings yet
Waiver of Parental Notice Handbook
17 pages
Commonwealth of Virginia Consent To Adoption
No ratings yet
Commonwealth of Virginia Consent To Adoption
2 pages
NY Family Court Habeas Corpus Petition
No ratings yet
NY Family Court Habeas Corpus Petition
5 pages
MCJC C#2019-005829
100% (1)
MCJC C#2019-005829
15 pages
Superior Court of California, County of Imperial 939 W. Main Street El Centro, CA 92243
No ratings yet
Superior Court of California, County of Imperial 939 W. Main Street El Centro, CA 92243
2 pages
Motion Attorneys Fees Sample - FL18586364
No ratings yet
Motion Attorneys Fees Sample - FL18586364
156 pages
.Citizens Dox Manual - Appendix
No ratings yet
.Citizens Dox Manual - Appendix
106 pages
AD887A
No ratings yet
AD887A
5 pages
NY Petition For Writ of Habeas Corpus
No ratings yet
NY Petition For Writ of Habeas Corpus
5 pages
Dependency Dogbook
No ratings yet
Dependency Dogbook
646 pages
Adopt200 Adoption Request
No ratings yet
Adopt200 Adoption Request
6 pages
Petition For Adoption
No ratings yet
Petition For Adoption
6 pages
Adoption Petition for Minors
No ratings yet
Adoption Petition for Minors
4 pages
Petition Appointment of Voluntary Guardian
No ratings yet
Petition Appointment of Voluntary Guardian
2 pages
20160130161345
No ratings yet
20160130161345
27 pages
flf028 2
No ratings yet
flf028 2
1 page
Family Law Court Order Request Guide
No ratings yet
Family Law Court Order Request Guide
4 pages
Figueroa Order 7 - 2023
No ratings yet
Figueroa Order 7 - 2023
4 pages
WWW Nycourts Gov)
No ratings yet
WWW Nycourts Gov)
7 pages
FL 341
No ratings yet
FL 341
2 pages
FL-105/GC-120: Superior Court of California, County of
No ratings yet
FL-105/GC-120: Superior Court of California, County of
2 pages
Hidalgo County NEW Final Protective Order.2021
100% (1)
Hidalgo County NEW Final Protective Order.2021
10 pages
FL - 105
No ratings yet
FL - 105
2 pages
Saul Salgado Mod Ivd Edited
No ratings yet
Saul Salgado Mod Ivd Edited
19 pages
DC 618
No ratings yet
DC 618
1 page
Form4-3 Temporary Orders
No ratings yet
Form4-3 Temporary Orders
27 pages
Susan Rubio Request
100% (1)
Susan Rubio Request
26 pages
Affidavit (Uniform Child Custody Jurisdiction and Enforcement Act)
No ratings yet
Affidavit (Uniform Child Custody Jurisdiction and Enforcement Act)
2 pages
Family Court Habeas Corpus Order
No ratings yet
Family Court Habeas Corpus Order
2 pages
Nouvel Exparte
100% (1)
Nouvel Exparte
27 pages
California Caregiver Affidavit Form
No ratings yet
California Caregiver Affidavit Form
4 pages
Probate Court of - County, Ohio - , Judge
No ratings yet
Probate Court of - County, Ohio - , Judge
3 pages
Indiana Parental Rights Termination
100% (2)
Indiana Parental Rights Termination
15 pages
Adopt 200
No ratings yet
Adopt 200
6 pages
20160130161221
No ratings yet
20160130161221
26 pages
FCA 467, 549, 651, 652,654 DRL 75-l, 240 General Form 17 (Petition-Custody, Visitation) 10/2012
No ratings yet
FCA 467, 549, 651, 652,654 DRL 75-l, 240 General Form 17 (Petition-Custody, Visitation) 10/2012
7 pages
NY Custody Petition
No ratings yet
NY Custody Petition
6 pages
CA Dogbook 2ed Online
No ratings yet
CA Dogbook 2ed Online
555 pages
Attorneys Representing - Dogbook - 2ed - Online PDF
No ratings yet
Attorneys Representing - Dogbook - 2ed - Online PDF
554 pages
3 Citation For Publication Under Welfare and Institutions Code Section 294
No ratings yet
3 Citation For Publication Under Welfare and Institutions Code Section 294
1 page
Tab 5 Bundle - 1
No ratings yet
Tab 5 Bundle - 1
22 pages
Juvenile Court Process Guide
0% (1)
Juvenile Court Process Guide
17 pages
6 Demand For Dismissal of Child Support Enforcement Proceedings
No ratings yet
6 Demand For Dismissal of Child Support Enforcement Proceedings
13 pages
Family Law Affidavit Guide
100% (2)
Family Law Affidavit Guide
28 pages
Demand For Dismissal of Child Support Enforcement Proceedings
98% (51)
Demand For Dismissal of Child Support Enforcement Proceedings
14 pages
2024 08 07 Maile's Uccjea
No ratings yet
2024 08 07 Maile's Uccjea
2 pages
HB730
No ratings yet
HB730
14 pages
OCBC LOC Case
No ratings yet
OCBC LOC Case
8 pages
English Evaluation Test - 5Th Form: (Reading Comprehension)
No ratings yet
English Evaluation Test - 5Th Form: (Reading Comprehension)
5 pages
Two-Vessel Spontaneous Coronary Artery Dissection Requiring LAD Stents Placement
No ratings yet
Two-Vessel Spontaneous Coronary Artery Dissection Requiring LAD Stents Placement
3 pages
Intermediate Learners' Reading Comprehension Factors
No ratings yet
Intermediate Learners' Reading Comprehension Factors
9 pages
Oh Yes Price List-Latest - 17JAN18
No ratings yet
Oh Yes Price List-Latest - 17JAN18
3 pages
Deurloo FS 2001 Scribd Review
No ratings yet
Deurloo FS 2001 Scribd Review
4 pages
Biuret Test
0% (1)
Biuret Test
3 pages
Rent Agreement - 2025
100% (1)
Rent Agreement - 2025
4 pages
McKinsey IT Proposal for DOI
100% (3)
McKinsey IT Proposal for DOI
8 pages
Henry-IV Part 1
No ratings yet
Henry-IV Part 1
4 pages
Topics Under Educational Administration
67% (3)
Topics Under Educational Administration
11 pages
Final - Nurture Phase - I (Advance Batch) MNS01E
No ratings yet
Final - Nurture Phase - I (Advance Batch) MNS01E
26 pages
Absolute and Relative Morality
No ratings yet
Absolute and Relative Morality
3 pages
GDR Ship Brochure TA Version ENG PBP V2
No ratings yet
GDR Ship Brochure TA Version ENG PBP V2
8 pages
ABC Unified Rules of Professional Kickboxing
No ratings yet
ABC Unified Rules of Professional Kickboxing
5 pages
Gerund 1
No ratings yet
Gerund 1
2 pages
Quarter 1 - Module 5: Incorporates The Design, Form, and Spirit of The Arts and Crafts of Luzon (Highlands and Lowlands)
100% (1)
Quarter 1 - Module 5: Incorporates The Design, Form, and Spirit of The Arts and Crafts of Luzon (Highlands and Lowlands)
16 pages
ws17 Tutorial Ntop Pres
No ratings yet
ws17 Tutorial Ntop Pres
122 pages
GROUP-30 Fire Opt Cum Driver
No ratings yet
GROUP-30 Fire Opt Cum Driver
3 pages
Liberal Temper in Greek Politics - BW
100% (1)
Liberal Temper in Greek Politics - BW
452 pages
Offshore Drilling Risk Framework
No ratings yet
Offshore Drilling Risk Framework
11 pages
Neet UG Major Test Series
No ratings yet
Neet UG Major Test Series
70 pages
Naguiat vs. Court of Appeals, 412 SCRA 591, October 03, 2003 PDF
No ratings yet
Naguiat vs. Court of Appeals, 412 SCRA 591, October 03, 2003 PDF
2 pages
T C C: I°: HE Ompass Lass
100% (2)
T C C: I°: HE Ompass Lass
6 pages
Infos Zu Kalang Village in Dolpo
No ratings yet
Infos Zu Kalang Village in Dolpo
4 pages
Milroy (1985) - Linguistic Change, Social Network and Speaker Innovation
No ratings yet
Milroy (1985) - Linguistic Change, Social Network and Speaker Innovation
47 pages
Stress Management Among Employees in It Companies
No ratings yet
Stress Management Among Employees in It Companies
14 pages
B.tech Civil Syllabus AR16 Revised
No ratings yet
B.tech Civil Syllabus AR16 Revised
227 pages
Plus One Grade 2 Study Pack Vol 1
No ratings yet
Plus One Grade 2 Study Pack Vol 1
47 pages
Extraction and Chemistry of Annatto PDF
No ratings yet
Extraction and Chemistry of Annatto PDF
10 pages