Free Emergency Custody Order Affidavit - Kentucky

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AOC-DNA-2.1 Rev. 9-02 Page 1 of 2

Case No.
01/9/2007 11:46 am

Court County EMERGENCY CUSTODY ORDER AFFIDAVIT

[ ] District

[ ] Family

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Ver. 1.01

Commonwealth of Kentucky Court of Justice www.kycourts.net

Division _____________________

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

I, ___________________________________________________, swear or affirm under oath the following statements are true to the best of my knowledge (if more space is needed, attach second page): ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Date: _________________, 2_____ Affiant's Signature: _______________________________________________

Affiant's Name (Print/Type): ___________________________________________________________________________ Address: _______________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Relation to Child: _________________________________________________ Phone No. _______________________ Child currently resides with: ________________________________________________________________________ Relation to Child: ____________________________________________________________________________________ Juvenile's Legal Mother: _____________________________________________________________________ Address: ___________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Phone No. _________________ [ ] Stepfather SSN _____________________ Legal Custodian? [ ] Yes [ ] No Name of Other(s) Living in Home and Relationship to Child: ______________________________________________________________________________ [ ] Sibling(s) _______________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ [ ] Other __________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

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AOC-DNA-2.1 Rev. 9-02 Page 2 of 2

Case No. _______________________

Juvenile's Legal Father: Address:

_____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________________ ___________________________________________________________________________________________ Phone No. _________________ [ ] Stepmother SSN _____________________ Legal Custodian? [ ] Yes [ ] No Name of Other(s) Living in Home and Relationship to Child: _____________________________________________________________________________ [ ] Sibling(s) _______________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ [ ] Other __________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

Subscribed and sworn to before me on ____________________, 2_____. My Commission expires: __________ _________________, 2_____. _________________________________, Clerk By: ______________________________ D.C.

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