Fillable Form 1: Page 1 of 4 Commonwealth of (Administrative Office of the Courts)

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Form 1: Page 1 of 4 Commonwealth of (Administrative Office of the Courts)

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BROWSE ADMINISTRATIVE OFFICE OF THE COURTS (KY) FORMS

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JUVENILE DEPENDENCY/NEGLECT OR ABUSE

PETITION

 W/ EMERGENCY CUSTODY ORDER AFFIDAVIT

lex

justitia

CLERK’S USE ONLY

Temporary Removal Hearing (TRH): Date _____________________, 2______ Time: _______  a.m.  p.m.

Location: ___________________________________________________________________________________

IN THE INTEREST OF: ____________________________________________________________________, A CHILD

DOB Sex Race SSN

Doc. Code: PJ or

AOC-DNA-1

Rev. 1-2

PJECA

Page 1 of 4

Commonwealth of Kentucky

Court of Justice

www.kycourts.gov

KRS 610.010, 620.023, .027, .050, .060,

.070, .080; FCRPP 19

Case No. ____________________

Court  District  Family

Division ______________________

County ______________________

Affiant, ________________________________________________________________________________________,

says that on _______________________, 2_____, in _______________________ County, Kentucky, the above-named

child was/is  dependent (UOR Code - 002813)  neglected or abused (UOR Code - 002826) pursuant to KRS

Chapter 620, and within the scope of KRS 610.010(2)(d); Affiant’s grounds of belief are:

_______________________________________________________________________________________________

1. 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: _________________________________________________________

2. 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

If Yes, please give the type of case and county, if known: ____________________________________________

_________________________________________________________________________________________.

3. Name of person believed responsible for  dependency  neglect or abuse:

____________________________________________________________________________________________.

5. Complete the following information:

AOC-DNA-1

Rev. 1-21

Page 2 of 4

Case No. ______________________________

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:

_________________________________________________________________________________________

_________________________________________________________________________________________.

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: _____________________________________________________________________________

_____________________________________________________________________________________

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.: _________________________

( )

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):

_________________________________________________________________________________________

_________________________________________________________________________________________.

( )

address

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AOC-DNA-1

Rev. 1-21

Page 3 of 4

Case No. ______________________________

 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:

_____________________________________________________________________________________________

 Name, address and relation of nearest known adult relative, if no parent or PECCS is located:

_____________________________________________________________________________________________

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: ______________________________________

( )

_____________________________________________

Notary Public or Circuit Clerk/D.C.

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: ____________________.

STATE OF _________________________

COUNTY OF ______________________

( )

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: _____________________________________________________________________________

_____________________________________________________________________________________

CHFS Use Only. Non-CHFS users must complete the AOC-DNA-2.1, Emergency Custody Order Aﬃ davit

EMERGENCY CUSTODY ORDER AFFIDAVIT* FOR CHFS

(*You may use this ECO Aﬃ davit instead of the AOC-DNA-2.1 if an ECO is being sought at the same time as this Petition

is ﬁ led. Use the AOC-DNA 2.1 ECO Aﬃ davit if you need more room to write or if the petition will be ﬁ led at a later time.)

I, _____________________________________________________, swear or aﬃ rm under oath the above statements

located in the ﬁ rst paragraph of the Petition are true to the best of my knowledge with respect to the above-named child.

There is an immediate risk to the child and the additional following facts support that removal from the home is the least

restrictive placement at this time:

_______________________________________________________________________________________________

Date: _______________________, 2_____ Aﬃ ant’s Signature: _________________________________________

Aﬃ ant’s Relationship to the child: ____________________________________________________________________

Distribution:  Court File  Parent(s)/custodian(s) (Sheriﬀ or other authorized person to serve, not a CHFS employee)

 Local DCBS  Local CASA upon Court referral

AOC-DNA-1

Rev. 1-21

Page 4 of 4

Case No. ______________________________

_____________________________________________

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: ____________________.

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Completed 21 January 2021

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