STATEMENT TO THE COURT OF PERMANENCY HEARING REPORT AND NOTICE SENT Confidential: For Court Use Only PERMANENCY HEARING DATE CERTAIN: Judge / Referee Agency Court / / Part Case Manager Name Caseworker Name Attorney for ACS/DSS IN THE MATTER OF: Child's Name Date of Birth Sex Person ID (PID) Docket Number / / / / THE PERMANENCY HEARING REPORT AND NOTICE WAS MAILED TO: A. PARENTS Parent's Name & Address Relationship Associated Child(ren) Date Mailed / / B. ATTORNEYS Attorney's Name & Address Associated Parent Date Mailed / / / / C. CHILD'S LAW GUARDIANS Law Guardian's Law Guardian Name Agency Name & Address Associated Child(ren) / / Date Mailed / / / / PH-4a Page 1 of 2 Confidential: For Court Use Only American LegalNet, Inc. www.USCourtForms.com STATEMENT TO THE COURT OF PERMANENCY HEARING REPORT AND NOTICE SENT Confidential: For Court Use Only D. AUTHORIZED AGENCY Authorized Agency Current Associated Name & Address Child(ren) Date Mailed / / E. FOSTER PARENTS Foster Parent's Name & Address Current Associated Child(ren) / / Date Mailed / / F. PRE-ADOPTIVE PARENTS / RELATIVES/ OTHERS Pre-Adoptive Parent's Relative's / Other's Current Associated Name & Address Name & Address Child(ren) / / Date Mailed / / THE NOTICE WAS MAILED TO: G. FORMER FOSTER PARENTS Former Foster Parent's Dates of Name & Address Placement Associated Child(ren) / / Date Mailed from / / to / / from / / to / / Name: / / / / _________________________________ (print) Signed: _________________________________ Title: __________________ Agency Name: __________________________ Agency Address: _________________________ _________________________ _________________________ Telephone Number: (______)______-________ PH-4a Page 2 of 2 Confidential: For Court Use Only American LegalNet, Inc. www.USCourtForms.com