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 an appeal has been filed on __________________ concerning the above-child from the following Orphans' Court order: An order An order An order An order granting granting granting granting denying the petition to relinquish parental rights of denying the petition to terminate parental rights of denying the petition to confirm consent of __________________. denying the petition for adoption. __________________. __________________. Date: _______ __ _ __________________________ On behalf of: American LegalNet, Inc. www.FormsWorkFlow.com