HARRY HUGHES, Governor

2353

IF YOU DISAGREE WITH THIS DECISION AND DESIRE TO
APPEAL, YOU MUST FILL IN THE FORM PROVIDED BELOW AND SEND IT
TO THE STATE'S ATTORNEY'S OFFICE SO THAT IT IS RECEIVED IN
THAT OFFICE BY (DATE)

IF YOU HAVE ANY QUESTIONS OR WANT TO TALK ABOUT THIS
CASE WITH ME BEFORE MAKING A DECISION ON WHETHER TO APPEAL,
PLEASE CALL ME AT (PHONE NUMBER) HOWEVER, IF YOU DO
THIS, IT WILL NOT EXTEND THE 15-DAY PERIOD WITHIN WHICH YOU
ARE ALLOWED TO APPEAL.

SINCERELY,

INTAKE OFFICER

IF YOU DISAGREE WITH THE ABOVE DECISION OF THE INTAKE
OFFICER, FILL OUT THE FORM BELOW AND SEND IT TO:

(NAME AND______________ (TO BE FILLED IN

ADDRESS OF APPROPRIATE BY INTAKE OFFICER
STATE'S ATTORNEY AUTHORITY) PRIOR TO MAILING

TO PERSON BEING
INFORMED OF INTAKE
DECISION)

(TO BE FILLED IN
BY INTAKE OFFICER
PRIOR TO MAILING
TO PERSON BEING
INFORMED OF INTAKE
DECISION)

I HAVE BEEN INFORMED BY THE JUVENILE INTAKE OFFICER OF
HIS DECISION NOT TO FORWARD THIS CASE FOR ACTION IN THE
JUVENILE COURT.

I DISAGREE WITH THIS DECISION AND ASK THAT THE STATE'S
ATTORNEY'S OFFICE REVIEW IT AND DECIDE WHETHER COURT
PROCEEDINGS SHOULD BE CARRIED OUT.

SIGNED

(B) THE USE OF THE FORM PRESCRIBED BY SUBSECTION (A)
OF THIS SECTION DOES NOT PRECLUDE THE JUVENILE SERVICES
ADMINISTRATION FROM SENDING OTHER INFORMATION, IN ADDITION
TO THIS FORM, TO EXPLAIN THE INTAKE OFFICER'S DECISION AND
ADVISE PERSONS OF THEIR RIGHT TO APPEAL THE DECISION OF THE
INTAKE OFFICER.

RE: ____________

OFFENSE:

DATE OF OFFENSE:

NATURE OF OFFENSE: