Jv365 Termination Of Juvenile Court Jurisdiction Page 2
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2JV-365
NONMINOR'S NAME:
CASE NUMBER:
3.
g.
An advance health care directive form ________
h.
Letter prepared by the county welfare department that includes the nonminor's name and date of birth, the dates during
which the he or she was within the jurisdiction of the juvenile court, and a statement that the nonminor was a foster child
in compliance with state and federal financial aid documentation requirements ________
i.
The nonminor's 90-day Transition Plan ________
j.
A blank copy of each of the following: How to Ask to Return to Juvenile Court Jurisdiction and Foster Care (form
JV-464-INFO), Request to Return to Juvenile Court Jurisdiction and Foster Care (form JV-466), and Confidential
Information-Request to Return to Juvenile Court Jurisdiction and Foster Care (form JV-468) ________
4.
If the nonminor continues to be eligible for services or accommodations under the Individuals With Disabilities Education Act,
the Americans With Disabilities Act, or section 504 of the Rehabilitation Act of 1973, he or she has been provided with his or
her most recent service or accommodation plan. ________
5.
The nonminor has been receiving services as provided in the Individuals With Disabilities Education Act (34 C.F.R.
§§ 300.320(b) and (c), 300.321(b)), and
a.
the nonminor has received his or her transition service plan. ________
the nonminor has been informed of the rights that will transfer to him or her under this act. ________
b.
The nonminor received the following:
6.
a.
Assistance with an application for Medi-Cal or other health insurance, including information about the availability of
extended Medi-Cal benefits until age 21 ________
Assistance with an application for college, a vocational training program, or other educational or employment
b.
program ________
c.
Assistance in obtaining financial aid for college, a vocational training program, or other educational or employment
program ________
A referral to transitional housing, if available, or assistance in securing other housing ________
d.
e.
Assistance in obtaining employment or other financial support including the CalFresh Program ________
f.
Assistance in maintaining relationships with individuals important to him or her, consistent with the his or her best interest
(required only if the nonminor has been in an out-of-home placement for six months or longer)
g.
Assistance in accessing the Independent Living Aftercare Program in the nonminor's county of residence
h.
Other services ordered by the court (specify):
7.
Number of pages attached:
8.
I declare under penalty of perjury under the laws of the State of California that the foregoing and all attachments are true and correct.
Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF SOCIAL WORKER OR PROBATION OFFICER)
I certify that I have received the information and services that I initialed above.
9.
Date:
(TYPE OR PRINT NAME)
(NONMINOR'S SIGNATURE)
Page 2 of 2
JV-365 [Rev. January 1, 2012]
TERMINATION OF JUVENILE COURT JURISDICTION—NONMINOR
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