IN THE COURT OF COMMON PLEAS COUNTY PENNSYLVANIA JUVENILE DIVISION In the Interest of _____________________, a Minor [Initials of Minor] Date of Birth Docket No.: CP- -DP- - TO CLERK OF [Title of Clerk Maintaining Dependency Docket] : Please kindly record the following in the CPCMS � Dependency Module: I hereby notify you that the appeal from the Orphans' Court order concerning the above-child has been disposed on __________________ in the following manner: Quashed Affirmed Reversed Vacated & Remanded Other: _________________________________________________________________ Date: ________ __ __________________________ On behalf of: American LegalNet, Inc. www.FormsWorkFlow.com