Juvenile Civil Citation

NEBRASKA JUVENILE CIVIL CITATION The undersigned being duly sworn says the below named juvenile offender, at or about date and time shown (date/time): _ __ at or near (location) in the City of _________________________ , in the County of ___________________, State of Nebraska, did unlawfully commit the following offense(s): (1) ____________________________________ (2) ____________________________________ (3) ____________________________________ AGENCY: ________________________ INCIDENT/CASE/REPORT NUMBER: ________________________ Citation Number: ______________ WARNING: Failure to provide information necessary for a peace officer to complete this civil citation will result in the juvenile's being taken into temporary custody. JUVENILE'S INFORMATION: NAME: RESIDENCE ADDRESS: (Last, First, MI) (Street Address) HOME PHONE: ALTERNATE PHONE: (City) (State) (Zip Code) DATE OF BIRTH: ____________________ RACE: ____________________ GENDER: Male or Female SCHOOL: __________________________ FATHER'S NAME: MOTHER'S NAME: GUARDIAN'S NAME: RESIDENCE ADDRESS: _________________________________________________________________________________________________ (Street Address) (City) (State) (Zip Code) In accordance with the Neb. Rev. Stat. § 43248.02(3) the abovenamed juvenile has the option to refuse the civil citation and be taken directly into temporary custody as provided in §§ 43248 and 43250. The option to refuse the civil citation may be exercised at any time prior to compliance with any services required by the Juvenile Assessment Center pursuant to § 43248.02(5). The Juvenile Assessment Center may require the juvenile to participate in community service or other available services appropriate to the needs of the juvenile which may include family counseling, urinalysis monitoring, or substance abuse and mental health treatment services. If the juvenile fails to comply with any services required, or if the juvenile is issued a third or subsequent civil citation, a peace officer shall take the juvenile into temporary custody as provided in §§ 43248 and 43250. I have been advised by the peace officer that I have the right to refuse this citation. I understand that if I choose to refuse this citation, I will be taken directly into temporary custody and the case will be referred for prosecution. I have been further advised that I may exercise this option any time prior to the completion of my Juvenile Assessment Center requirements. _____________________________ Juvenile's Signature _____________________________ Officer's Printed Name _____________________________ Officer's Signature _______________ Date _______________ Badge/Serial Number _______________ Date _____________________________ ________________ Parent/Guardian's Signature Date _____________________________ Parent/Guardian's Printed Name The juvenile shall appear within 72 hours after the issuance of this Civil Citation to: Douglas County Juvenile Assessment Center (JAC) 1941 S. 42nd Street, Suite 504, 68105 (402) 4446464 WARNING: Failure to appear in accordance with the command of this civil citation will result in the juvenile's being taken into temporary custody. Form effective July 15, 2010. American LegalNet, Inc. www.FormsWorkFlow.com