TO COMMUNITY JUSTICE PROGRAM:
This notice serves as a referral by the Superior Court, Family Division to your community justice program
pursuant to 33 V.S.A. § 5232 (b)(7). The youth has been instructed to contact you within a week of the
date of the referral Order. Please use this form to communicate with the Court. Enclosed are a copy of
the Referral Order, Petition and Affidavit, and victim impact statement (if one has been filed with the
Court).
Please note: juvenile matters are CONFIDENTIAL. Unlawful dissemination of information is a crime
punishable by a fine up to $2,000. 33 V.S.A. § 5117 (b)(2). Any records or reports relating to a matter
within the jurisdiction of this Court shall not be disseminated by the receiving persons or agencies to any
persons or agencies, other than those persons or agencies authorized to receive documents. 33 V.S.A. §
5117 (e).
COMMUNITY JUSTICE PROGRAM
NOTICE TO COURT
Docket #: ____________________________
Most Current Address for Youth
_____________________________________
_____________________________________
Date: _____________________________________
Youth’s Name & Date of Birth
In Re: _____________________________________
Date of Birth: _______________________________
TO SUPERIOR COURT, FAMILY DIVISION:
This is to inform you that the above-named client:
☐ failed to contact this Community Justice Program within 7 days of the Court’s referral.
☐ was not accepted by the Community Justice Program.
☐ failed to complete the Program.
☐ successfully compete the Community Justice Program
Date
_____________________________ ______________________________________
Signature of Community Justice Staff Person
______________________________________
Printed Name
cc: Client/Youth
State’s Attorney
Court
400-00124 – Referral to Approved Community Justice Program (10/2019) Page 2 of 2
