Commonwealth of Pennsylvania Court of Common Pleas ­ Juvenile Division County of [Name] Judicial District In the Interest Of: ______________________, a Minor Docket No: CP- -DP-20 FID: -FN-20 County Local No: ___________________ FILING TYPE Dependency Petition Aggravated Circumstances Alleged (Attached) Initiated by Private Petition Name: Address: Shelter Care Application Application for Emergency Protective Custody PETITIONER / AGENCY Phone: IN THE INTEREST OF: Name: Address: Age: Phone Number(s): DOB: Sex: Phone Type: Race: Asian/Pacific Islander Black White Bi-Racial Unknown/Unreported American Indian/Alaskan Native Tribal Affiliation: Ethnicity: Hispanic Not Hispanic Unknown CASE INFORMATION Type of Dependency: The child named above comes within the jurisdiction of the court as defined by The Juvenile Act at 42 Pa.C.S.§6302. Abuse and/or Neglect Status Offense (1) is without proper care or control (2) has been placed for care or adoption in violation of law (3) has been abandoned (4) is without a parent, guardian, or legal custodian (10) is born to a parent whose parental rights with regard to another child have been involuntarily terminated (5) while subject to compulsory school attendance is habitually and without justification truant from school (6) has committed a specific act or acts of habitual disobedience (7) is under the age of ten years and has committed a delinquent act (8) has been formerly adjudicated dependent, and is under the jurisdiction of the court (9) has been referred pursuant to section 6323 (relating to informal adjustment), and who commits an act which is defined as ungovernable in paragraph (6) Abuse: The petition alleges that the above named child is a victim of child abuse as defined at 23 Pa.C.S. §6303. Protective Custody: Child is NOT in Protective Custody Child is in Protective Custody (removed from the home) and Location of the child is: under supervision of the county agency Child remains in home but is in imminent risk of placement Date: Time: in foster care absent preventive services. Location of the child is: CHILD'S PARENTS AND/OR OTHER LEGAL GUARDIAN OR CUSTODIAN Mother's Name: DOB: Address: Father's Name: DOB: Address: Legal Guardian's or Custodian's Name: Relationship: Address: DOB: Phone Number(s): Phone Type: Phone Number(s): Phone Type: Phone Number(s): Phone Type: Whereabouts Unknown Whereabouts Unknown Closest Relative ­ If whereabouts unknown for Parents and Guardian Name: Address: Phone Number: Relation to Child: Attorney's Name: Address: Supreme Court ID: AOPC Form Updated Rev 8/4/2016 Whereabouts Unknown Additional Participants with Relationship to Child (see attached) CHILD'S ATTORNEY/GUARDIAN AD LITEM Guardian Ad Litem's Name: Address: Supreme Court ID: Petition/Application Cover, Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com In the Interest Of: ______________________, a Minor ADDITIONAL PARTICIPANTS WITH RELATIONSHIP TO CHILD Name DOB Address (Indicate if Whereabouts Unknown) Phone (indicate type ex: Cell Phone) Relationship to Child AOPC Form Updated Rev 8/4/2016 Petition/Application Cover, Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com