Fillable JUVENILE PROBATION CERTIFICATE Delinquency Youthful Offender (Vermont Judiciary)

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JUVENILE PROBATION CERTIFICATE Delinquency Youthful Offender (Vermont Judiciary)

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400-00106 - Juvenile Probation Certificate (4/2020) Page 1 of 4
STATE OF VERMONT
SUPERIOR COURT
FAMILY DIVISION
Unit
Docket No.
In Re:
DOB
JUVENILE PROBATION CERTIFICATE
☐ Delinquency
☐ Youthful Offender
Date of Adjudication: __________________________
Date of Majority: __________________________
Date of Disposition: __________________________
To: ___________________________________________
You have been found by the Court to have committed the following delinquent act(s):
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
At a hearing held on _______________, the Judge placed you on probation. Failure to comply with the
conditions of your probation certificate may result in a graduated sanction, a violation of probation filing, placement
at a secure juvenile facility, or incarceration at an adult correctional facility if you are 18 or older. A finding that you
have violated your probation could result in additional probation conditions, an extension of the term of probation, a
change in custody, placement at a secure juvenile facility, or (if you are 18 or older) incarceration at an adult
correctional facility. The Court orders that you follow these conditions while you are on probation:
☐ 1. You shall actively participate in a restorative process and complete all conditions set forth. Members that
participate in the process will sign an agreement that restricts any discussion of your case to their
participation in the panel process. In order to participate in the process, you will have to tell the members
about the facts of your offense and take responsibility. The members of the restorative process shall not
order financial restitution of more than $_______________.
☐ 2. Perform __________ hours of community service, to be completed by _______________.
☐ 3. Pay restitution of $_______________ dollars according to the following schedule:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
☐ 4. For the duration of your probation, do not associate with the following individuals without prior approval of
your probation officer: ________________________________________________________________
☐ 5. You shall not harass, nor cause anyone else to harass, the following: _______________________________
☐ 6. Do not go to the following place: _________________________________________________________, unless
approved by your Probation Officer.
☐ 7. Be home at __________________________________________________________________________, or
with your parent/guardian or other adult approved by the Court or probation officer during the following
hours: __________ to __________, unless modified by your probation officer.
400-00106 - Juvenile Probation Certificate (4/2020) Page 2 of 4
☐ 8 Do
not have any weapons or other destructive devices on you or accessible to you at your home, including
(but not limited to) firearms, ammunition, explosives, and bows.
☐ 9. When your probation officer reasonably suspects that you have been using drugs or alcohol, your probation
officer may require you to submit to a urine and/or breath test for drugs or alcohol.
☐ 10. You shall successfully complete a treatment program at ______________________________________.
☐ 11. Be drug and alcohol free. Do not buy, possess, or use alcohol, marijuana, illegal drugs, or any regulated drugs
unless they are prescribed to you by a medical provider.
☐ 12. Faithfully attend school or training at _____________________________________________________.
☐ 13. Work faithfully at ____________________________________________________ or seek employment.
☐ 14. Remain within the State of Vermont unless granted permission to leave by your probation officer.
☐ 15. Reside at ___________________________________________________________________________.
☐ 16. You shall submit to a drug or alcohol assessment and follow recommendations for treatment.
☐ 17. Notify your probation officer within 24 hours of any change of address or place of residence.
☐ 18. Report to your juvenile probation officer as directed. Answer all reasonable inquiries by your juvenile
probation officer.
☐ 19. Allow your juvenile probation officer to visit you at reasonable times at home or elsewhere.
☐ 20. Sign appropriate releases of information to allow your probation officer to monitor the compliance with your
probation conditions.
☐ 21 For Youthful Offender Only: Participate in electronic monitoring as directed by your probation officer and
abide by all electronic monitoring, user agreements, controls and conditions as directed.
☐ 22. Other: ______________________________________________________________________________
Special Conditions Related to Sexual Offenses
☐ 23. You shall successfully enroll, participate in, and complete a program/treatment for sex offenders as directed
by your probation officer or designee.
☐ 24. You shall not have any contact with your victim(s) __________________________________________
(Victim’s Initials)
(including letters, phone calls, tapes, visits, videos, electronically or any form of contact through a third party)
unless approved and documented in advance by your probation officer.
☐ 25. You may not purchase, possess, or use pornography or erotica. You may not go to adult book stores, sex
shops, topless bars.
☐ 26. You may not own, possess or use a camera, recorder, cell phone, or other electronic device that has recording
capabilities, without prior permission of your probation officer or designee. If permission is granted you must
enable your probation officer to access these devices to monitor compliance with probation conditions.
☐ 27. You may not access or loiter in places where children congregate; e.g., parks, playgrounds, schools, etc., unless
otherwise approved and documented in advance by your probation officer.
400-00106 - Juvenile Probation Certificate (4/2020) Page 3 of 4
☐ 28. You will inform all persons who your therapist and/or probation officer determine should be informed of your
sexual offending history.
☐ 29. Other: __________________________________________________________________________________
☐ Dis
charge from probation is to be reviewed at a Review Hearing scheduled for __________ months from the date
of this order.
Probation will be termed and be discharged
on _______________, unless that date is changed by order of the Court.
Ple
ase circle the risk level as determined by YASI that supports your recommendation:
Overall Protective
Factors
Overall Risk Level on
YASI
Recommended Length of Probation
High
Low Risk
Moderate Risk 3- 6 months
High Risk 6–12 months
Moderate
Lo
w Risk 3-6 months
Moderate Risk 6-9 months
High Risk 9–12 months
Low
Low Risk 3-6 months
Moderate Risk 6-12 months
High Risk 12–24 months
Dated
_____________________________ ___________________________________
Superior Court Judge
400-00106 - Juvenile Probation Certificate (4/2020) Page 4 of 4
Youth’s Acknowledgment of Receipt of the Probation Conditions
I, _______________________________________
,
have received a copy of this Probation Certificate. I have
read the above conditions of probation and I have had them explained to me. I understand them and agree to follow
them. I understand that violations of any of the conditions may cause the Court to issue a pick-up order for my
apprehension. Additional conditions may be imposed upon me or I may be placed at a secure juvenile facility. I also
understand that if I do not comply with any of the above conditions, if I am found by a judge to be delinquent in the
future, or if I am later convicted of an adult crime, the Court may find me in violation of probation. I understand that
the Court can then give me more conditions to complete and take other appropriate action, such as revocation of
probation. 33 V.S.A §5263(b).
Parent/Guardian Acknowledgment
I, _________________________________________, the parent/ guardian of __________________________,
have read the above conditions of probation ordered by the Court and understand them. I agree to facilitate
and support my child’s compliance with these conditions. I agree to attend treatment programs with my child as
recommended by the treatment provider. 33 V.S.A. §5263(c). I understand that adjudication of further delinquent
acts, conviction of a crime, and / or violation of any of the above conditions is a violation of probation and may result
in further court action.
Signatures:
Juvenile / Youth Date
Parent / Guardian Date
Parent / Guardian
Date
Guardian Ad Litem
Date
DCF Probation Officer Date
DOC Probation Officer Date
If you have any questions about the conditions of probation, please call: __________________________
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JUVENILE PROBATION CERTIFICATE Delinquency Youthful Offender (Vermont Judiciary)

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Completed 30 July 2020

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