Form AOC-JV-41 "Affidavit and Truancy Evaluation Form" - Kentucky

What Is Form AOC-JV-41?

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 June 1, 2016;
  • The latest edition provided by the Kentucky Court of Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form AOC-JV-41 by clicking the link below or browse more documents and templates provided by the Kentucky Court of Justice.

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Download Form AOC-JV-41 "Affidavit and Truancy Evaluation Form" - Kentucky

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AOC-JV-41
Doc. Code: ATE
CDW Referral No. _____________
Rev. 6-16
Juv Id: __________
Page 1 of 2
l e x
Case No. ____________________
e t
j u s t i t i a
Commonwealth of Kentucky
Court
[ ] Family
[ ] District
Court of Justice
www.courts.ky.gov
AFFIDAVIT AND TRUANCY
County ______________________
EVALUATION FORM
KRS 159.140; 605.020; 630.060
Demographic Information:
Name:
DOB:
Grade:
Race:
Gender:
School:
SSN:
Mother:
Father:
Other Legal Guardian(s):
Relationship:
Student resides with:
(Please check all that apply)
q Both Parents
Parent's Resident Address:
Mailing Address(if different than above):
Home Phone:
Cell Phone:
Work Phone:
q Mother
Mother's Resident Address:
Mailing Address(if different than above):
Home Phone:
Cell Phone:
Work Phone:
q Father
Father's Resident Address:
Mailing Address(if different than above):
Home Phone:
Cell Phone:
Work Phone:
q Other/Legal Guardian
Other/Legal Guardian Resident Address:
Mailing Address(if different than above):
Home Phone:
Cell Phone:
Work Phone:
Truancy Information:
Total Absences:
Absences Unexcused:
Total Tardies:
Tardies Unexcused:
Total Days Not Enrolled:
How many school years has this student been habitually truant:
School Issues:
(Please check all that apply)
q Skipping School
q Skipping Classes
q Behavior Issues
q Low Academic Performance
q Suspensions (# of events ____)
q Suspected Gang Involvement
q Suspected Drug Involvement
q Suspected Alcohol Use
q Bullying/Safety Concerns
q Poor Peer Relationships
q 504 Plan
q IEP (Last ARC Date: ____________)
Other School Concerns:
AOC-JV-41
Doc. Code: ATE
CDW Referral No. _____________
Rev. 6-16
Juv Id: __________
Page 1 of 2
l e x
Case No. ____________________
e t
j u s t i t i a
Commonwealth of Kentucky
Court
[ ] Family
[ ] District
Court of Justice
www.courts.ky.gov
AFFIDAVIT AND TRUANCY
County ______________________
EVALUATION FORM
KRS 159.140; 605.020; 630.060
Demographic Information:
Name:
DOB:
Grade:
Race:
Gender:
School:
SSN:
Mother:
Father:
Other Legal Guardian(s):
Relationship:
Student resides with:
(Please check all that apply)
q Both Parents
Parent's Resident Address:
Mailing Address(if different than above):
Home Phone:
Cell Phone:
Work Phone:
q Mother
Mother's Resident Address:
Mailing Address(if different than above):
Home Phone:
Cell Phone:
Work Phone:
q Father
Father's Resident Address:
Mailing Address(if different than above):
Home Phone:
Cell Phone:
Work Phone:
q Other/Legal Guardian
Other/Legal Guardian Resident Address:
Mailing Address(if different than above):
Home Phone:
Cell Phone:
Work Phone:
Truancy Information:
Total Absences:
Absences Unexcused:
Total Tardies:
Tardies Unexcused:
Total Days Not Enrolled:
How many school years has this student been habitually truant:
School Issues:
(Please check all that apply)
q Skipping School
q Skipping Classes
q Behavior Issues
q Low Academic Performance
q Suspensions (# of events ____)
q Suspected Gang Involvement
q Suspected Drug Involvement
q Suspected Alcohol Use
q Bullying/Safety Concerns
q Poor Peer Relationships
q 504 Plan
q IEP (Last ARC Date: ____________)
Other School Concerns:
AOC-JV-41
Rev 4-16
Page 2 of 2
Basic Needs Not Met In The Home:
q Food
q Clothing
q Shelter
q Medical
q Books
q Parental Care
q Other (Describe):
List any concerns from home visit(s):
What referrals or resources have been provided:
Causes of irregular attendance and truancy: (Describe the issues causing truancy.)
Interventions By School for Truancy
:
(Please list dates of the following interventions attach a contact log if one is available.)
Phone Calls:
Date Final Notice was Delivered:
Final Notice Delivery Method:
Letters Sent:
q Hand Delivery
q Certified Mail
Parent Conference:
Person who signed/Received Notice:
Student Conference:
__________________________________________
Home Visit(s):
Person Refused to Sign: q
Other:
Did parent/guardian ever attend a Truancy Diversion Program meeting? q Yes
q No
q Not Offered
Additional pertinent information for the court, if any:
This form was:
Prepared by: _____________________________________________
________________________
Name
Title
_____________________________________________
________________________
Phone No. and Email
Date
Affidavit
I, _____________________________________, the undersigned Affiant, state that I have read the foregoing
and that the matters stated herein are true to the best of my information, knowledge, and belief.
____________________________________________
Signature
____________________________________________
Printed name
SWORN TO before me this _________ day of ___________________________, 2_____.
Name _________________________________________
Title ________________________________________
Please attach the following reports: l Attendance l Behavior l Grades l FRYSC (if applicable)
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