U Commonwealth of Kentucky Court of Justice www.courts.ky.gov RT OF JUS TI C E AOC-DNA-18 Rev. 1-15 Page 1 of 2 COM M O NW E A LT H O F K E lex et justitia Case No. ____________________ Court [ ] District [ ] Family County ______________________ Division _____________________ NT U C KY STIPULATION OF FACTS & WAIVER OF FORMAL ADJUDICATION HEARING [ ] Dependency [ ] Neglect or Abuse IN THE INTEREST OF: ____________________________________________________________________, A CHILD DOB Sex Race SSN The following is a Stipulation regarding the petition currently before the court in the above-referenced case: 1. The child(ren) was/were properly before the court pursuant to KRS 610.010 and 610.020. 2. The child(ren) is/are represented by counsel duly appointed by this Court whose name is: ___________________________________________________________________ 3. The parent(s) or other person exercising custodial control or supervision were represented by: ____________________________________________ for the Mother; ____________________________________________ for the Father; and/or ____________________________________________ for other person exercising custodial control or supervision; OR have been advised of their right to counsel and waived same. 4. The party or parties signing this document is/are not under the influence of alcohol, medication, drugs or mental condition that would prevent them from understanding these proceedings or stipulating of their own free will. 5. The party or parties stipulate to the following facts which support a legal finding of [ ] dependency [ ] neglect or abuse: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 6. [ ] The party or parties understand that by entering into this Stipulation he/she/they agree to waive (give up their rights to) a formal adjudication hearing or trial contesting the facts stated above where the Commonwealth would be required to prove the contents of the Petition; a right to confront and cross-examine witnesses; to have witnesses appear in court on their behalf; a right not to incriminate or testify against oneself; and a right to appeal, and also understand(s) the court will continue to have authority to make decisions regarding custody of the child(ren). 7. [ ] The Agreed Disposition will be as follows because the child and his/her counsel have waived a separate Disposition. (KRS 610.080) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ [ ] Pending Disposition it is further agreed as follows: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com CO AOC-DNA-18 Rev. 1-15 Page 2 of 2 Case No. ___________________________ ______________________________________________ Counsel for the Child ______________________________________________ Mother ______________________________________________ Father ______________________________________________ Other Person Exercising Custodial Control or Supervision (PECCS) Have seen and agree: _____________________________________________ County Attorney ___________________________________________ CHFS Representative ____________________________________________ Mother's attorney ____________________________________________ Father's attorney ____________________________________________ PECCS's attorney DISTRIBUTION: [ ] Court file [ ] CHFS or agency where child is placed [ ] All counsel of record and/or parents/PECCS of child not represented by counsel American LegalNet, Inc. www.FormsWorkFlow.com