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 following has been filed on __________________ with the Orphans' Court in __________________ County concerning the above-child: An order An order An order 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 _________________________. _________________________. _________________________. With the above-order relinquishing or terminating parental rights or confirming the consent of the parent(s), the child is available for adoption. Do not check if at least one parent still has parental rights. An order granting denying the petition for adoption. Date: _________ _ __________________________ On behalf of: American LegalNet, Inc. www.FormsWorkFlow.com