[Note to Court Clerk: Enter requestor as non-party participant in CV and route directly to judicial officer.] IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of (use initials only): ) ) ) ) ) ) ) A minor under 18 years of age. Date of birth: 1. 2. CASE NO. REQUEST FOR REVIEW HEARING ON PLACEMENT DENIAL I am an adult family member or adult family friend of the minor child(ren) named above. The Office of Children's Services denied placement of the child(ren) with me because: 3. I do not agree with the placement decision made by the Office of Children's Services. I believe that the child(ren) should be placed with me because: 4. I request a hearing to review the placement decision. I understand that my participation in this case is limited to participating in the hearing about denial of placement with me. Attached is a copy of the denial notice from the Office of Children's Services. Date Signature Type or Print Name Mailing Address City State Daytime Phone Number ORDER ZIP IT IS ORDERED that the request for review hearing is GRANTED. A review hearing will be held on at a.m./p.m., at Date (For Court Use Only) I certify that on sI sent copies of this order to: Clerk: CN-313 (5/15)(cs) REQUEST FOR REVIEW HEARING ON PLACEMENT DENIAL Judge Type or Print Name AS 47.14.100(m); Irma E., 312 P.3d 850; CINA Rule 19.1(e) American LegalNet, Inc. www.FormsWorkFlow.com