C110A - Application for a care or supervision order and other orders under Part 4 of the Children Act 1989 or
an Emergency Protection Order under section 44 of the Children Act 1989 (04.14) © Crown copyright 2014
C110A
To be completed by the court
The family court sitting at
Case number Date issued
Child(ren)’s name(s)
Fee charged
Application for a care or supervision
order and other orders under Part
4 of the Children Act 1989 or an
Emergency Protection Order under
section 44 of the Children Act 1989
Name of applicant
Full name of respondent(s)
Nature of application
Care and supervision or other Part 4
Care
Supervision
Interim care order
Interim supervision order
Other (please specify)
Is the Local Authority considering adoption?
Yes No
If Yes, please complete Section 7b
Emergency Protection Order
information on the whereabouts of the child[ren]
(Section 48(1) Children Act 1989).
authorisation for entry of premises
(Section 48(3) Children Act 1989).
authorisation to search for another child on the
premises (Section 48(4) Children Act 1989).
Other (please specify)
Is an urgent hearing required?
Yes No
If Yes, complete Section 1
Is a without notice hearing required?
Yes No
If Yes, complete Section 2
Are there previous or ongoing proceedings for the child(ren)?
Yes No
If Yes, complete Section 3
Are there factors aecting litigation capacity?
Yes No
If Yes, complete Section 4
Is this a case with an international element?
Yes No
If Yes, complete Section 5
Additional information required
What order(s) are you applying for? (tick all which apply)
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2
Child 1 - Full name of child Date of birth
Order(s) applied for
(including interim orders)
D D
/
M M
/
Y Y Y Y
Is the child accommodated?
Yes No
If Yes, from what date?
D D
/
M M
/
Y Y Y Y
Name of mother Name of father Parental Responsibility
Yes No
Summary of
childrens details
Child 2 - Full name of child Date of birth
Order(s) applied for
(including interim orders)
D D
/
M M
/
Y Y Y Y
Is the child accommodated?
Yes No
If Yes, from what date?
D D
/
M M
/
Y Y Y Y
Name of mother Name of father Parental Responsibility
Yes No
Child 3 - Full name of child Date of birth
Order(s) applied for
(including interim orders)
D D
/
M M
/
Y Y Y Y
Is the child accommodated?
Yes No
If Yes, from what date?
D D
/
M M
/
Y Y Y Y
Name of mother Name of father Parental Responsibility
Yes No
Child 4 - Full name of child Date of birth
Order(s) applied for
(including interim orders)
D D
/
M M
/
Y Y Y Y
Is the child accommodated?
Yes No
If Yes, from what date?
D D
/
M M
/
Y Y Y Y
Name of mother Name of father Parental Responsibility
Yes No
3
1. Is the application for urgent consideration?
Complete this section if you have ticked the relevant box on the front of
the form
Proposed timetable
The application should be considered within hours/days
If consideration is sought within 48 hours, you must complete the section
below
What eorts have been made to put
each respondent on notice of the
application?
Is the urgent hearing for:
(tick as required)
Contested ICO
EPO
urgent preliminary Case Management Hearing
Set out the order(s)/directions sought
Set out the reasons for urgency
Part A - All applications
4
B – The grounds are
Any applicant
that there is reasonable cause to believe that [this] [these] child[ren] [is]
[are] likely to suer signicant harm if
or
the child[ren] [is] [are] not removed to accommodation
provided by or on behalf of this applicant
or
the child[ren] [does] [do] not remain in the place where
[the child] [they] [is] [are] currently being accommodated.
Local authority applicants
that enquiries are being made about the welfare of the child[ren] under
Section 47(1)(b) of Children Act 1989 and those enquiries are being
frustrated by access to the child[ren] being unreasonably refused to
someone who is authorised to seek access and there is reasonable cause to
believe that access to the child[ren] is required as a matter of urgency.
Authorised person applicants
that there is reasonable cause to suspect that the child[ren] [is] [are]
suering, or [is] [are] likely to suer, signicant harm and enquiries
are being made with respect to the welfare of the child[ren] and
those enquiries are being frustrated by access to the child[ren] being
unreasonably refused to someone who is authorised to seek access and
there is reasonable cause to believe that access to the child[ren] is required
as a matter of urgency.
C – The additional
order(s) applied for
information on the whereabouts of the child[ren]
(Section 48(1) Children Act 1989).
authorisation for entry of premises (Section 48(3) Children Act 1989).
authorisation to search for another child on the premises
(Section 48(4) Children Act 1989).
D – The direction(s) sought
contact with any named person (Section 44(6)(a) Children Act 1989).
a medical or psychiatric examination or other assessment of the child[ren]
(Section 44(6)(b) Children Act 1989).
to be accompanied by a registered medical practitioner, registered nurse
or registered midwife (Section 45(12) Children Act 1989).
an exclusion requirement (Section 44A(1) Children Act 1989).
If the application is for an Emergency Protection Order only,
please complete B, C and D as appropriate
5
Complete this section if you have ticked the relevant box on the front of
the form
Set out the order/directions
sought
Set out the reasons for the
application to be considered
without notice. (This information
is a requirement, a without notice
hearing will not be directed
without reason)
Do you require a without notice
hearing because it is not possible
to give notice including abridged
or informal notice?
Yes No
If Yes, please set out reasons below
Do you require a without notice
hearing because notice to a
respondent will frustrate the
order that is being applied for?
Yes No
If Yes, please set out reasons below
Other (please specify)
2. Is the application for a without notice hearing?
6
Complete this section if you have ticked the relevant box on the front of
this form.
Please give details (include
name of child(ren), case no.,
date(s) of application, dates
proceedings concluded, order
made)
Please also provide the name of
any children’s guardian who has
been involved in any previous
or ongoing proceedings
involving a child of one or both
respondents
Is continuity of the childrens
guardian required?
Yes No
If No, why not?
3. Previous or ongoing proceedings
7
4. Factors aecting ability to participate in proceedings
Complete this section if you have ticked the relevant box on the front of
this form.
Please give details of any factors
aecting litigation capacity
Provide details of any referral to or
assessment by the Adult Learning
Disability team, and/or any adult
health service, where known,
together with the outcome
Are you aware of any other factors
which may aect the ability of the
person concerned to take part in
the proceedings?
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5. Cases with an international element
Complete this section if you have ticked the relevant box on the front of
this form.
Do you have any reason to
believe that any child, parent or
potentially signicant adult in
the child’s life may be habitually
resident in another state?
Yes No
If Yes, please give details
Do you have any reason to
believe that there may be an
issue as to jurisdiction in
this case (for example under
Brussels 2 revised)?
Yes No
If Yes, please give details
Has a request been made or
should a request be made to
a Central Authority or other
competent authority in a foreign
state or a consular authority in
England and Wales?
Yes No
If Yes, please give details
9
Set out in not more than the two
following pages the threshold
criteria relied upon
6. Grounds for the application
The grounds for the application
are that the child(ren) is suering
or is likely to suer, signicant
harm and the harm or likelihood
of harm is because the child is:
not receiving care that would be reasonably expected from a parent
beyond parental control
10
Continued from overleaf – Set out
the threshold criteria relied upon
11
7. Plans for the child(ren)
7a. Please give a brief summary of
the plans for the child(ren).
The summary must include any
contact arrangements that are in
place or are proposed.
What is the local authoritys
proposal including placement and
support services and are there
any requirements which the local
authority wish the court to impose
under Part 1 of Schedule 3 Children
Act 1989?
It is not sucient just to refer to or repeat the Care Plan.
7b. Having regard to s. 22
Adoption and Children Act 2002
is the local authority considering
adoption?
Yes No
Does the application for a
placement order(s) accompany
this application?
Yes No
If not, why not and when will it
be submitted?
Have you notied the relevant
Central Authority or the
competent authority in the
foreign state in cases to which
section 5 of this form applies?
Yes No
12
8. Timetable for the child(ren)
The timetable for the child will be set by the court to take account of dates of
the signicant steps in the child’s life that are likely to take place during the
proceedings. Those steps include not only legal steps, but also social, care,
health, education and developmental steps and any timetable for a case with
an international element.
Please give any relevant dates/events
in relation to the child(ren)
• it may be necessary to give
dierent dates for each child.
Are you aware of any signicant
event in the timetable, before
which the case should be
concluded?
Yes No
If Yes, please give a date
D D
/
M M
/
Y Y Y Y
and give your reasons
By what date should the child(ren)
be placed on a permanent basis?
Name of child
D D
/
M M
/
Y Y Y Y
Name of child
D D
/
M M
/
Y Y Y Y
Name of child
D D
/
M M
/
Y Y Y Y
Name of child
D D
/
M M
/
Y Y Y Y
Please give your reasons
13
9. Attending the court
If an interpreter will be required, you must tell the court now so that one
can be arranged.
If Yes, please specify the language and dialect:
Are you aware of whether an
interpreter will be required?
Yes No
If attending the court, do any of the
parties involved have a disability for
which special assistance or special
facilities would be required?
Yes No
If Yes, please specify what the needs are:
Please state whether the court
needs to make any special
arrangements for the parties
attending court (e.g. providing a
separate waiting room or other
security requirements).
Court sta may get in contact with you about the requirements
Yes No
If Yes, please give details
Are you aware of whether an
intermediary will be required?
14
10. Allocation proposal
Judicial continuity
Please give the following details of
other proceedings:
Case number
Name of Judge
Date of last relevant order
Are proceedings nished or
outstanding?
Finished Outstanding
Applicant’s allocation proposal
Lay justices
District Judge level
Circuit Judge level
DFJ/Section 9 sitting as a Judge of the High Court
High Court Judge level
Set out the applicable
paragraphs of the schedule to
the Presidents Guidance on the
distribution of business
Part 2 (To be completed by the Court)
Allocation decision in
accordance with the Allocation
Rules and the Presidents
Guidance on the distribution of
business
Lay justices
District Judge level
Circuit Judge level
High Court Judge level
Listed for
Case Management Hearing
Time Date
D D
/
M M
/
Y Y Y Y
Part 1 (To be completed by the
applicant Local Authority on issue)
15
Location
of court
or
Name of Judge
District Judge
Legal Adviser
Date
D D
/
M M
/
Y Y Y Y
Allocated by
11. Signature
Print full name
Your role/position held
The facts in this application are true to the best of my knowledge and belief
and the opinions set out are my own.
Signed
Applicant
Date
D D
/
M M
/
Y Y Y Y
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Solicitors name
Address
Telephone number
Mobile telephone number
Fax number
Email
DX number
Solicitors Reference
The applicant
Name of applicant
(local authority or authorised person)
Name of contact
Job title
Address
Contact telephone number
Mobile telephone number
Fax number
Email
DX number
Solicitor’s details
Postcode
Postcode
Details of parties – please complete this section in full
17
The respondents
If there are more than two respondents please continue on a separate sheet.
Respondent’s full name
Date of birth
D D
/
M M
/
Y Y Y Y
Gender Male Female
Place of birth
(town/county/country, if known)
Current address
Telephone number
Relationship to the child(ren)
Name of child(ren) Relationship Parental Responsibility
Yes No
Yes No
Yes No
Yes No
Respondent 1
Postcode
Respondent’s full name
Date of birth
D D
/
M M
/
Y Y Y Y
Gender Male Female
Place of birth
(town/county/country, if known)
Current address
Telephone number
Relationship to the child(ren)
Name of child(ren) Relationship Parental Responsibility
Yes No
Yes No
Yes No
Yes No
Respondent 2
Postcode
18
The child(ren)
Please give details of the child(ren) and the order(s) you are applying for.
If there are more than four children please continue on a separate sheet.
Child 1
Child’s full name
Date of birth
D D
/
M M
/
Y Y Y Y
Gender Male Female
Name of social worker and
telephone number
If the child is not
accommodated, who does the
child live with?
At which address does
the child live?
Postcode
Child 2
Child’s full name
Date of birth
D D
/
M M
/
Y Y Y Y
Gender Male Female
Name of social worker and
telephone number
If the child is not
accommodated, who does the
child live with?
At which address does
the child live?
Postcode
19
Child 3
Child’s full name
Date of birth
D D
/
M M
/
Y Y Y Y
Gender Male Female
Name of social worker and
telephone number
If the child is not
accommodated, who does the
child live with?
At which address does
the child live?
Postcode
Child 4
Child’s full name
Date of birth
D D
/
M M
/
Y Y Y Y
Gender Male Female
Name of social worker and
telephone number
If the child is not
accommodated, who does the
child live with?
At which address does
the child live?
Postcode
If more than four children, continue on a separate sheet.
20
Others who should be given notice
Persons full name
Date of birth
D D
/
M M
/
Y Y Y Y
Gender Male Female
Address
Relationship to the child(ren)
Name of child Relationship Parental Responsibility
Yes No
Yes No
Yes No
Yes No
Relationship to the respondents
Name of respondent Relationship
Person 1
Postcode
Persons full name
Date of birth
D D
/
M M
/
Y Y Y Y
Gender Male Female
Address
Relationship to the child(ren)
Name of child Relationship Parental Responsibility
Yes No
Yes No
Yes No
Yes No
Relationship to the respondents
Name of respondent Relationship
Person 2
Postcode
21
Annex Documents
1. Social Work Chronology attached to follow
(A succinct summary)
If to follow please give reasons why not included and the date when the
document will be sent to the court.
2. Social Work Statement and
genogram
attached to follow
If to follow please give reasons why not included and the date when the
document will be sent to the court.
3. The current assessment
relating to the child and/or
the family and friends of the
child to which the Social Work
Statement refers and on which
the local authority relies
attached to follow
If to follow please give reasons why not included and the date when the
document will be sent to the court.
4. Care plan attached to follow
If to follow please give reasons why not included and the date when the
document will be sent to the court.
5. Index of checklist documents attached to follow
If to follow please give reasons why not included and the date when the
document will be sent to the court.
This annex must be completed by the applicant with any application for a care, supervision or other Part 4 order.
The documents specied in this annex must be led with the application if available.
If any relevant document is not led with the application, the reason and any expected date of ling must be stated.
All documents led with the application must be clearly marked with their title and numbered consecutively.
22
What to do once you have completed this form
Ensure that you have:
attached copies of any annex documents.
signed the form at Section 11.
provided a copy of the application and attached documents for each of the respondents, and for
Cafcass or CAFCASS CYMRU.
given details of the additional children if there are more than four.
given details of the additional respondents if there are more than two.
the correct fee.
It is good practice to inform Cafcass or CAFCASS CYMRU that you are making this application. The court will
expect the local authority to have informed Cafcass or CAFCASS CYMRU that proceedings are being issued.
Have you notied Cafcass - Children and Family Court Advisory and Support Service (for England)
or
CAFCASS CYMRU - Children and Family Court Advisory and Support Service Wales.
Yes No
If Yes, please give the date of notication
D D
/
M M
/
Y Y Y Y
Now take or send your application with the correct fee and four copies to the court.
Please refer to the Family Proceedings Fees Order for the correct fee in respect of your application.
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