Fillable EMERGENCY CUSTODY ORDER AFFIDAVIT AOC-DNA-2.1 Page 1 of (Administrative Office of the Courts)

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EMERGENCY CUSTODY ORDER AFFIDAVIT AOC-DNA-2.1 Page 1 of (Administrative Office of the Courts)

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Doc. Code: AECO
AOC-DNA-2.1
Rev. 1-21
Page 1 of 3
Commonwealth of Kentucky
Court of Justice www.kycourts.gov
KRS 620.060; FCRPP 18
EMERGENCY CUSTODY ORDER
AFFIDAVIT
IN THE INTEREST OF: ____________________________________________________________________, A CHILD
DOB Sex Race SSN
I, __________________________________________________, swear or affi rm under oath the following statements
are true to the best of my knowledge (if more space is needed, attach second page):
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
______________________________________________________________________________________________.
1. The statements above create reason to believe that the following condition(s) exist: (check all that apply)
The child is in danger of imminent death or serious physical injury or is being sexually abused;
The parent(s) has/have repeatedly infl icted or allowed to be infl icted by other than accidental means physical
injury or emotional injury; and/or
The child is in immediate danger due to the failure or refusal of the parent(s) to provide for the safety or needs of
the child.
2. As required by KRS 620.030(1) I have made a report regarding these facts to the following entity:
Local law enforcement Cabinet for Health & Family Services
Kentucky State Police Commonwealth Attorney
County Attorney Did not report
If you did not report, please explain why: ________________________________________________________
3. To your knowledge, are there, or have there been, any court or Cabinet cases or proceedings related to the child
in this county or any other county/state? Yes No
Case No. _____________________
Court District Family
County ______________________
Division ______________________
NOTE: This form may be used to request a temporary emergency custody order (ECO). If an ECO is not granted, you
may fi le a dependency, neglect and abuse action using the AOC-DNA-1, Juvenile Dependency/Neglect or Abuse Petition.
AOC-DNA-2.1
Rev. 1-21
Case No. ___________________________
Page 2 of 3
Juvenile’s Legal Mother: _______________________________________________________________
Address: _____________________________________________________________________________
_____________________________________________________________________________________
Email Address (if known)
: _________________________________________
Phone No.: _______________ SSN: _______________ DOB: ___________ Legal Custodian? Yes No
Name of Other(s) Living in Mother’s Home and relationship to the Child:
Stepparent: _________________________________________________________________________
Sibling(s): __________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Other: _____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
( )
( )
4. a. If removal from the custodial parent is requested, has the non-custodial parent been contacted for placement
of the child? Yes No
If No, was the non-custodial parent considered for placement? Yes No
b. Is there any existing Order which restricts placement with the non-custodial parent? Yes No
If Yes, list state, county, case number and date of order if known (or attach copy if available):
______________________________________________________________________________________
c. Is there any other reason the non-custodial parent was not considered for placement? Yes No
If Yes, please explain why the non-custodial parent was not contacted or considered for placement:
______________________________________________________________________________________
______________________________________________________________________________________
5. Complete the following information:
Juvenile’s Address(es):
Juvenile currently resides at _________________________________________________________________
with Mother Father Other ____________________________________.
Juvenile ordinarily resides at (if diff erent from above) _____________________________________________
with Mother Father Other ____________________________________.
Juvenile will reside at (if known) _______________________________________________________________
with Mother Father Other ___________________________________.(please explain below)
_______________________________________________________________________________________
Juvenile attends school at __________________________________________________________________.
Juvenile's Phone No.: __________________________
address (county)
address (county)
address (county)
AOC-DNA-2.1
Rev. 1-21
Case No. ___________________________
Page 3 of 3
Distribution: Court fi le
Affi ant states the foregoing allegations are true based upon information and belief.
Affi ant’s Name (Print/Type): ________________________________________________________________________
Affi ant's Address: _________________________________________________________________________________
_________________________________________________________________________________
Affi ant's Relationship to the Child: __________________________________ Phone No. ______________________
Date: ____________________, 2_______ Affi ant’s Signature: _______________________________________
( )
Name, address and relation of other person(s) exercising custodial control or supervision of the child (PECCS)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Email Address (if known): __________________________________________
Phone No.: _______________ SSN: _______________ DOB: ___________ Legal Custodian? Yes No
Name of Other(s) Living in the PECCS’s Home and relationship to the Child:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
( )
( )
_____________________________________________
Notary Public or Circuit Clerk/D.C.
STATE OF _________________________
COUNTY OF ______________________
Subscribed and sworn to before me in my presence via oral communication on this the _____ day of
____________________, 2______, at _______ a.m. p.m.
If a Notary: My commission expires: ____________________.
Juvenile’s Legal Father: _______________________________________________________________
Address: _____________________________________________________________________________
_____________________________________________________________________________________
Email Address (if known)
: _________________________________________
Phone No.: _______________ SSN: _______________ DOB: ___________ Legal Custodian? Yes No
Name of Other(s) Living in Father’s Home and relationship to the Child:
Stepparent: _________________________________________________________________________
Sibling(s): __________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Other: _____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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EMERGENCY CUSTODY ORDER AFFIDAVIT AOC-DNA-2.1 Page 1 of (Administrative Office of the Courts)

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Completed 5 January 2022

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