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: A petition to relinquish parental rights of _________________________. A petition to terminate parental rights of __________________________. A petition to confirm consent of __________________________. A petition for adoption ___________________________. Date: ________ __ __________________________ On behalf of: American LegalNet, Inc. www.FormsWorkFlow.com