lexet justitia COMMONWEALTHOFKENTUCKY COURTOFJUSTICE AOC-DNA-2.1 Doc. Code: AECO en-USRev. 7-18en-USPage 1 of 3 en-USCommonwealth of Kentuckyen-USCourt of Justice en-US www.courts.ky.goven-USKRS 620.060; FCRPP 18en-USEMERGENCY CUSTODY ORDERen-USAFFIDAVITen-USIN THE INTEREST OF: , A CHILD DOB þ Sex þ þ Race þ SSN en-USen-USare true ten-USo the best of my knowledge (en-USif more space is needed, attach second page ): þ en-USen-USen-USen-USen-USen-USen-USen-USen-USen-US.en-USAs required by KRS 620.030(1) I have made a report regarding these facts to the following entity: þ en-US Local law enforcement þ en-USen-US Cabinet for Health & Family Services þ en-US Kentucky State Police þ en-USen-US Commonwealth Attorney þ en-US County Attorney þ en-USen-US Did not reporten-USIf you did not report, please explain why: en-USJuvenile222s Address(es): en-USJuvenile currently resides at en-USwith en-USen-US Mother en-USen-US Father en-USen-US Other .en-USJuvenile ordinarily resides at en-USen-USen-USwith en-USen-US Mother en-USen-US Father en-USen-US Other en-US.en-USJuvenile will reside at en-US(if known)en-US en-USwith en-USen-US Mother en-USen-US Father en-USen-US Other .en-US(pleaen-USse explain below)en-USen-USJuvenile attends school at .en-USJuvenile's Phone No. en-US( )en-USCase No. en-USCourt en-USen-US District en-USen-US Family en-USCounty en-USDivision þ addressþ (county) þ addressþ (county) þ addressþ (county) American LegalNet, Inc. www.FormsWorkFlow.com en-USAOC-DNA-2.1 Rev. 7-18þ Case No. Page 2 of 3 en-USJuvenile222s Legal en-USFather:en-US en-USAddress: en-USen-USen-USPhone No.: SSN: DOB: Legal Custodian? en-USen-US Yes en-USen-US Noen-USName of Other(s) Living in Father222s Home and relationship to Child:en-US þ Stepparent en-US þ Sibling(s) þ þ en-US þ Other þ þ en-US en-USJuvenile222s Legal Mother:en-US en-USen-USAddress: en-USen-USen-USPhone No.: SSN: DOB: Legal Custodian? en-USen-US Yes en-USen-US Noen-USName of Other(s) Living in Mother222s Home and relationship to Child:en-US þ Stepparent en-US þ Sibling(s) þ en-USen-US þ Other en-USen-USen-US en-US( )en-US( )en-USIf removal from the custodial parent(s) is requested has the non-custodial parent been contacted for placement en-USof the child? en-USen-US Yes en-USen-US No. If No, is there any existing Order which restricts placement with the non-custodial en-USparent? en-USen-US Yes en-USen-US No en-USen-US Unknown. If yes, list state, county, case number and date of order if known (or attach en-UScopy if available): en-USen-USAre there other proceedings pending in this or any other jurisdiction? en-USen-US Yes en-USen-US Noen-USIf yes, please explain: en-USen-US American LegalNet, Inc. www.FormsWorkFlow.com en-USAOC-DNA-2.1 Rev. 7-18þ Case No. Page 3 of 3 en-USDistribution: en-USen-USen-USen-US(Print/Typeen-US): en-USAddress: en-US en-US en-USRelation to Chilen-USd: en-US Phone No. þ en-US( )en-USSworn ten-USo before me on , 2. My Commission expires: , 2. þ þ en-US en-USen-US Name þ en-US Title en-USen-US Name, address and relation of other person exercising custodial control or supervision of the child (PECCS) en-USen-USen-USPhone No.: SSN: DOB: Legal Custodian? en-USen-US Yes en-USen-US Noen-USName of Other(s) Living in the PECCS222s Home and relationship to the Child:en-USen-USen-USen-US en-US( ) American LegalNet, Inc. www.FormsWorkFlow.com