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1 of 2 JUV-3 JUV-3 Children in Need of Services (CHINS) Complaint CHILDREN IN NEED OF SERVICES (CHINS) COMPLAINT IN THE JUVENILE COURT OF DAWSON COUNTY, GEORGIA File Name: (Last, F, Age: AKA: DOB: Race: Lives Res Phone: Sex: With: Bus Phone: School: Grade: SS#: Child’s Address: (Street) (City) (County) (State) (Zip) Does the child receive special education services? If so, explain: Mother’s Res Phone: Name: Bus Phone: (Include Mother’s Maiden Name in Parentheses) Mother’s Address: (Street) (City) (County) (State) (Zip) Father’s Res Phone: Name: Bus Phone: Father’s Address: (Street) (City) (County) (State) (Zip) Legal Res Phone: Custodian: Bus Phone: Custodian’s Address: (Street) (City) (County) (State) (Zip) Other household members and their DOB. If none of the preceding applies, adult relative nearest the Court: Taken into Custody: Yes ( ) No ( ) By Whom: (Name) (Agency) Placement of Date: Dependent Child: Time: Person Notified: Date: By: Via: Time: ---PAGE BREAK--- 2 of 2 JUV-3 FILE Detained: Yes ( ) No ( ) Place Date: Authorized By: Detained: Time: Released To: Date: Relation: Time: 1. State the facts supporting this court’s jurisdiction: 2. State the reason why this complaint is in the best interest of the child: 3. Have all available and appropriate attempts to encourage voluntary use of community services by the child’s family been exhausted? (Yes/No): 4. State the name of any public institution or agency having the responsibility or ability to supply services alleged to be needed by the child: 5. If the complainant is a School District, have you sought to resolve the problem through available educational approaches? (Yes/No/NA): 6. If the complainant is a School District, have you sought to engage the parent, guardian or legal custodian of the child in solving the problem, but such person has been unwilling or unable to do so, that the problem remains, and court intervention is needed? (Yes/No/NA): 7. If the complainant is a School District, has a determination been made that the child is eligible or suspected to be eligible under the federal Individuals with Disabilities Education Act or section 504 of the federal Rehabilitation Act of 1973? (Yes/No/NA): 8. If the complainant is a School District, have you reviewed the appropriateness of said child’s Individual Education Plan (IEP) and placement and made modification where appropriate? (Yes/No/NA): 9. Is any information required by O.C.G.A. § 15-11-390(b) unknown? If so, what? Investigating Agency: Officer: P.D. Report Phone Complainant’s Name: Signature: Date: Complainant’s Address: Res Bus Phone: