en-USJUVENILE DEPENDENCY/NEGLECT OR ABUSE en-USPETITIONen-USen-US W/ EMERGENCY CUSTODY ORDER AFFIDAVIT lexet justitia COMMONWEALTHOFKENTUCKY COURTOFJUSTICE AOC-DNA-1 � Doc Code: PJ or Rev. 7-18 � 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 � Sex � � Race � SSN � 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 � � � � � � � � � � � � � � en-USen-USen-USen-USen-USen-USen-USen-USen-US 1. � As en-US required by KRS en-US620.030(1) I have made a report regarding these facts to the following entity: � en-US Local law enforcement � en-USen-US Cabinet for Health & Family Services � en-US Kentucky State Police � en-USen-US Commonwealth Attorney � en-USen-US County Attorney � en-USen-US Did not report � If you did not r en-USeport, please explain why: � en-US 2. � en-USAre th ere other proceedings pending in this or any other jurisdiction? � en-USen-US Yes en-USen-US No � If yes, please explain: en-US � en-USen-USen-US 3. � Name of pe en-USrson believed responsible for en-USen-US dependency en-USen-US neglect or abuse: � en-USen-USen-US 4. � If remo en-USval froen-USm the custodial parent is requested, has the non-custodial parent been contacted for placement of � 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. � Is there any existing Order which restricts placement with the non-custodial parent? en-USen-US Yes en-USen-US No. � 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 � the above pl en-USeen-USase explain why the non-custodial parent was not considered: � en-US � � en-US American LegalNet, Inc. www.FormsWorkFlow.com en-USAOC-DNA-1 Rev. 7-18� Case No. Page 2 of 3 en-USJuvenile222s Address: en-USen-US � 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. � 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 � Stepparent en-US � Sibling(s) � � en-US � Other � � en-USName of Other(s) Living in Father222s Home and relationship to Child:en-US � Stepparent en-US � Sibling(s) � � en-US � Other � � 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. 7-18� 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: � � � � � � � � � � � � � � � en-USen-USTelephone No. en-USen-US( )en-USSworn to before me on , 2. My Commission expires: , 2. � � � en-US en-US Name � en-USen-US Title en-USen-USEMERGENCY CUSTODY ORDER AFFIDAVIT* FOR CHFS en-US(en-US*This en-USen-USen-US)en-USI, � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 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 � � � � � � � � � � � � � � � � en-USen-USen-USen-US � � � � � en-USen-US Relaen-UStionship to the child: Distribution: � en-US Court File � en-US � � � � � � � � � � � � en-USother authorized person to serve, en-USnoten-US a CHFS employee) � en-US Local DCBS � en-USen-US Local CASA upon Court referralen-USSworn to before me on , 2. My Commission expires: , 2. � Name � � en-US en-USen-US Title American LegalNet, Inc. www.FormsWorkFlow.com