Free Juvenile Dependency, Neglect and Abuse Petition - Kentucky

AOC-DNA-1 Rev. 10-08 Page 1 of 2 Commonwealth of Kentucky Court of Justice www.courts.ky.gov KRS 610.010, 620.023, .027, .050, .060, .070, .080

COMM

O

NW

EA L TH OF KE
lex et justitia

Case No._____________________ Court [ ] District [ ] Family County_______________________ Division ______________________

NT

UCKY

RT

OF JUS

TI

JUVENILE DEPENDENCY, NEGLECT AND ABUSE PETITION

CLERK'S USE ONLY Hearing Date __________________, 2______ Hearing Time ______________ [ ] a.m. [ ] p.m. Hearing Location ____________________________________________________________________________ __________________________________________________________________________________________

IN THE INTEREST OF: ____________________________________________________________________, A CHILD Birthdate Sex Race SSN

Affiant,__________________________________________________________________________________, says that on ________________, 2_____, in _______________________ County, Kentucky, the above-named juvenile was/is [ ] dependent (UOR Code - 002813) [ ] neglected (UOR Code - 002814) [ ] abused (UOR Code - 002815) pursuanttoKRSChapter620etseqandwithinthescopeofKRS610.010(2)(d);Affiant'sgroundsofbeliefare:______ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Name of person believed responsible for neglect and/or abuse _________________________________________ Juvenile's Address: _______________________________________________________________________________________________ _______________________________________________________________________________________________ ________________________________________________________________ Telephone No. __________________ Juvenile attends school at __________________________________________________________________________ Affiant's Name (print) _____________________________________________________________________________ Affiant'sAddress_________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Telephone No. _____________________ Distribution: Court File Local DCBS Parent or other person exercising custodial control or supervision (sheriff to serve) Local CASA Project Director upon Court referral

Print

C

CO

U

E

Reset Form

AOC-DNA-1 Rev. 10-08 Page 2 of 2

Case No. ___________________

Juvenile's Legal Mother: _______________________________________________________________ Address: _____________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Phone No. _________________ SSN _____________________ Legal Custodian? [ ] Yes [ ] No Name of Other(s) Living in Mother's Home and relationship to Child: [ ] Stepfather ________________________________________________________________________ [ ] Sibling(s) ________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ [ ] Other ___________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Juvenile's Legal Father: _______________________________________________________________ Address: _____________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Phone No. _________________ SSN _____________________ Legal Custodian? [ ] Yes [ ] No Name of Other(s) Living in Father's Home and relationship to Child: [ ] Stepmother _______________________________________________________________________ [ ] Sibling(s) ________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ [ ] Other ___________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
[ ] Name and relation of other person exercising custody or control of child _____________________________ _____________________________________________________________________________________________ [ ] Name and address of nearest known adult relative if no parent or person exercising custodial control or supervision (PECC) is located: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Affiant states the foregoing allegations are true based upon information and belief. Affiant'sSignature______________________________________________________________________________ Sworn to before me on ___________________, 2_____. My Commission expires: _________________, 2_____. ______________________________________________ Name ______________________________________________ Title

Print

Reset Form