en-USJUVENILE DEPENDENCY/NEGLECT OR ABUSE en-USPETITIONen-USen-US W/ EMERGENCY CUSTODY ORDER AFFIDAVIT lexet justitia COMMONWEALTHOFKENTUCKY COURTOFJUSTICE AOC-DNA-1 þ Doc Code: PJ or Rev. 7-18 þ PJECA en-USPage 1 of 3en-USCommonen-USwealth of Kentuckyen-USCourt of Justice en-USwww.courts.ky.goven-USKRS 6en-US10en-US.010, 620.023, .027, .050, en-US.060, .070, .080; FCRPP 19en-USCase No.en-USCourt [ ] District [ ] Family en-USCountyen-USDivision en-USen-USCLERK222S USE ONLYen-USTemporary Removal Hearing (TRH)en-US: Date , 2 Time: en-USen-US a.m. en-USen-US p.m.en-USLocation: en-USIN THE INTEREST OF: , A CHILD DOB þ Sex þ þ Race þ SSN þ en-USsays that on , 2, in County, Kentucky, the above-named en-USjuvenile was/is en-USen-US en-USdependenten-US (UOR Code - 002813) en-USen-US en-USneglected or abuseden-US (UOR Code - 002826) pursuant en-USto KRS þ þ þ þ þ þ þ þ þ þ þ þ þ þ en-USen-USen-USen-USen-USen-USen-USen-USen-US 1. þ As en-US required by KRS en-US620.030(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-USen-US County Attorney þ en-USen-US Did not report þ If you did not r en-USeport, please explain why: þ en-US 2. þ en-USAre th ere other proceedings pending in this or any other jurisdiction? þ en-USen-US Yes en-USen-US No þ If yes, please explain: en-US þ en-USen-USen-US 3. þ Name of pe en-USrson believed responsible for en-USen-US dependency en-USen-US neglect or abuse: þ en-USen-USen-US 4. þ If remo en-USval froen-USm the custodial parent is requested, has the non-custodial parent been contacted for placement of þ en-USthe child? en-USen-US Yes en-USen-US No. If No, was the non-custodial parent considered for placement? en-USen-US Yes en-USen-US No. þ Is there any existing Order which restricts placement with the non-custodial parent? en-USen-US Yes en-USen-US No. þ Is there any other reason non-custodial parent was not considered for placement? en-USen-US Yes en-USen-US No. If no to any of þ the above pl en-USeen-USase explain why the non-custodial parent was not considered: þ en-US þ þ en-US American LegalNet, Inc. www.FormsWorkFlow.com en-USAOC-DNA-1 Rev. 7-18þ Case No. Page 2 of 3 en-USJuvenile222s Address: en-USen-US þ Phone No. en-USJuvenile currently resides with en-USen-US Mother en-USen-US Father en-USen-US Other en-USJuvenile atteen-USnds school at en-US( ) 5. þ Complete the following information: 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 No en-USJuvenile222s Legal Father:en-US en-USAddress: en-USen-USen-USPhone No.: SSN: DOB: Legal Custodian? en-USen-US Yes en-USen-US No en-USName of Other(s) Living in Mother222s Home and relationship to Child:en-US þ Stepparent en-US þ Sibling(s) þ þ en-US þ Other þ þ en-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-USen-US Name, address and relation of other en-USperson 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 No en-US( )en-US( ) American LegalNet, Inc. www.FormsWorkFlow.com en-USAOC-DNA-1 Rev. 7-18þ Case No. Page 3 of 3 en-USen-US Name, address and relation of en-USnearest known adult relative,en-US if no parent or person exercising custodial control or en-USsupervision (PECCS) is located: en-USen-USen-USen-USen-USDate: þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ en-USen-USTelephone No. en-USen-US( )en-USSworn to before me on , 2. My Commission expires: , 2. þ þ þ en-US en-US Name þ en-USen-US Title en-USen-USEMERGENCY CUSTODY ORDER AFFIDAVIT* FOR CHFS en-US(en-US*This en-USen-USen-US)en-USI, þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ en-USIn addition, I believe the additional following facts support that removal from the home is the least restrictive placement en-USat this time: en-USen-USen-USen-USWhat is þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ en-USen-USen-USen-US þ þ þ þ þ en-USen-US Relaen-UStionship to the child: Distribution: þ en-US Court File þ en-US þ þ þ þ þ þ þ þ þ þ þ þ en-USother authorized person to serve, en-USnoten-US a CHFS employee) þ en-US Local DCBS þ en-USen-US Local CASA upon Court referralen-USSworn to before me on , 2. My Commission expires: , 2. þ Name þ þ en-US en-USen-US Title American LegalNet, Inc. www.FormsWorkFlow.com