NORTH CAROLINA WAKE COUNTY IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION FILE NO. __________________ Assigned Judge: In the matter of: ABUSE/NEGLECT DEPENDENCY INFORMATION SHEET Notice to Calendar Request to Calendar Request to Appoint Request to Issue Writ Notification of Adoption Petition Date Requested: __________________ NOTICE TO CALENDAR Initial Nonsecure Custody Hearing Adjudication/Disposition Hearing Termination of Parental Rights (WCHS or GAL) Date: Date: Date: _______________ _______________ _______________ REQUEST TO CALENDAR / TYPE OF SETTING Review Type: _______________________________ TPR (private) Motion Type: _______________________________ Other: _____________________________ consent to this hearing date OR there is an objection I have consulted attorneys for all parties and all to this hearing date. Reason for objection (if known) phone fax I attempted to contact attorneys for all parties by have not received a response from all parties regarding this date. email on _______________ and REQUEST TO APPOINT Temporarily appointed attorney/GAL for the following parent(s): GAL also Previously appointed attorney/GAL (if any): ____________________ ____________________ GAL also Previously appointed attorney/GAL (if any): ____________________ ____________________ GAL also Previously appointed attorney/GAL (if any): ____________________ ____________________ Conflict GAL-AA for Juvenile(s) Attorney(s) with conflicts in this case: ______________________________________________________ TERMINATION OF PARENTAL RIGHTS Attorney for parent (Affidavit of Indigency filed and approved) Attorney representing parent in underlying case: _______________________________________________ GAL for parent GAL for parent in underlying case: __________________________________________________________ Conflict GAL-AA for Juvenile (private TPR-Answer filed) WAKE-JUV(AND)-5 (NEW 02/06) (PAGE 1 of 2) American LegalNet, Inc. www.FormsWorkFlow.com REQUEST TO ISSUE WRIT Name of Incarcerated Parent: _________________________________________________ M F Race_________________________ DOC # _________________________________ SSN: _____-_____-___________ Date of Birth: ________________________ Date and Time of Hearing _____________________________ NOTIFICATION OF ADOPTION PETITION An adoption petition was filed on ____________________. This completes the permanency plan for each child in this matter. A PTPR hearing is scheduled on ____________________. Please remove it from the calendar. ______________________ Date ____________________________________________ Print Name of Attorney/Social Worker ____________________________________________ Signature of Attorney/Social Worker ******************************************************************************************* CERTIFICATE OF SERVICE I hereby certify that a copy of this ABUSE/NEGLECT/DEPENDENCY INFORMATION SHEET has been submitted to the Clerk of Superior Court/Special Proceedings Division/Supervisor and the Family Court Office and served in the following manner: By hand delivery to _______________________________________________________________ By email to ______________________________________________________________________ By facsimile to ___________________________________________________________________ Other __________________________________________________________________________ I hereby certify that a copy of this ABUSE/NEGLECT/DEPENDENCY INFORMATION SHEETNotification of Adoption Petition was provided to the Wake County Attorneys' Office, the Guardian ad Litem Program or the Conflict Guardian ad Litem-Attorney Advocate in the following manner: By depositing a copy in the US Mail in a properly addressed, postpaid envelope to: _______________________________________ Wake County Attorney's Office P.O. Box 550 Raleigh, NC 27602 _________________________________ GAL Attorney Advocate P.O. Box 1107 Raleigh, NC 27602 By hand delivery to _________________________________________________________________ By email to ________________________________________________________________________ By facsimile to _____________________________________________________________________ Other _____________________________________________________________________________ _______________________ Date ___________________________________________ Print Name of Attorney/Social Worker ___________________________________________ Signature WAKE-JUV(AND)-5 (NEW 02/06) (PAGE 2 of 2) American LegalNet, Inc. www.FormsWorkFlow.com