Form AOC-DNA-1 "Juvenile Dependency/Neglect or Abuse Petition" - Kentucky

What Is Form AOC-DNA-1?

This is a legal form that was released by the Kentucky Court of Justice - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2021;
  • The latest edition provided by the Kentucky Court of Justice;
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  • Fill out the form in our online filing application.

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AOC-DNA-1
Doc. Code: PJ or
Case No. ____________________
Rev. 1-21
PJECA
l e x
Page 1 of 4
e t
Court
 District
 Family
j u s t i t i a
Commonwealth of Kentucky
Division ______________________
Court of Justice
www.kycourts.gov
JUVENILE DEPENDENCY/NEGLECT OR ABUSE
KRS
610.010, 620.023, .027, .050, .060,
PETITION
County ______________________
.070, .080; FCRPP 19
W/ EMERGENCY CUSTODY ORDER AFFIDAVIT
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
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:
____________________________________________________________________________________________.
AOC-DNA-1
Doc. Code: PJ or
Case No. ____________________
Rev. 1-21
PJECA
l e x
Page 1 of 4
e t
Court
 District
 Family
j u s t i t i a
Commonwealth of Kentucky
Division ______________________
Court of Justice
www.kycourts.gov
JUVENILE DEPENDENCY/NEGLECT OR ABUSE
KRS
610.010, 620.023, .027, .050, .060,
PETITION
County ______________________
.070, .080; FCRPP 19
W/ EMERGENCY CUSTODY ORDER AFFIDAVIT
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
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:
____________________________________________________________________________________________.
AOC-DNA-1
Rev. 1-21
Case No. ______________________________
Page 2 of 4
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 _________________________________________________________________
address
(county)
with  Mother  Father  Other ____________________________________.
Juvenile ordinarily resides at (if diff erent from above) ______________________________________________
address
(county)
with  Mother  Father  Other ____________________________________.
Juvenile will reside at (if known) _______________________________________________________________
address
(county)
with  Mother  Father  Other ___________________________________.(please explain below)
______________________________________________________________________________________
Juvenile attends school at _______________________________________________________________.
Juvenile's Phone No.: _________________________
(
)
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: _____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
AOC-DNA-1
Rev. 1-21
Case No. ______________________________
Page 3 of 4
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: _____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
 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: ______________________________________
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: ____________________.
_____________________________________________
Notary Public or Circuit Clerk/D.C.
AOC-DNA-1
Rev. 1-21
Case No. ______________________________
Page 4 of 4
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: ____________________________________________________________________
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: ____________________.
_____________________________________________
Notary Public or Circuit Clerk/D.C.
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
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