COVER SHEET STATE OF ARKANSAS CIRCUIT COURT: JUVENILE DEPENDENCY-NEGLECT & FINS Page 6/1/2017 Additional juveniles & parents: Juvenile Juvenile Last Name Last Name Suffix Suffix First Name First Name Middle name Middle name DL/State ID / Contexte ID DL/State ID / Contexte ID SSN SSN Date of Birth Date of birth Sex Male Female Sex Male Female Ethnicity Hispanic Non - Hispanic Ethnicity Hispanic Non - Hispanic Race Race Removal date Removal date Education Plan IEP 504 N/A Education Plan IEP 504 N/A School status School status Interpreter needed? Yes: No other language: Interpreter needed? Yes: No other language: Parent/Guardian Parent/Guardian Last Name Last Name Suffix Suffix First Name First Name Middle Name Middle Name DL/State ID / Contexte ID DL/State ID / Contexte ID Address Address City, State ZIP City, State ZIP Phone Phone Email Email Date of Birth Date of birth SSN SSN Interpreter needed? Yes: No other language: Interpreter needed? Yes: No other language: Parent of child(ren): Parent of American LegalNet, Inc. www.FormsWorkFlow.com