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Commonwealth of Pennsylvania 
Court of Common Pleas – Juvenile Division 
County of            
           Judicial District 

       

FILING TYPE 

In the Interest Of: 
______________________, a Minor 

 

Docket No:     
FID:      

  County Local No: ___________________ 

 Dependency Petition        

Shelter Care Application              

 Application for Emergency  

     
     

 Aggravated Circumstances Alleged (Attached) 
 Initiated by Private Petition  

     Protective Custody   

Name:            

Name:            

Address:           

           

Race:   

 Asian/Pacific Islander 
 Black  
 Caucasian  

PETITIONER / AGENCY 

Address:              
           

IN THE INTEREST OF: 

Phone:            

Age:            

DOB:            

Sex:            

Phone Number(s):  

Phone Type:  

           
           

 Bi-Racial 
 Native   Tribal Affiliation:              
 Unknown/Unreported 

CASE INFORMATION 

           
           

Ethnicity: 

 Hispanic  
 Not Hispanic 
 Unknown 

Type of Dependency: The child named above comes within the jurisdiction of the court as defined by The Juvenile Act at 42 Pa.C.S.§6302.  
Abuse and/or Neglect          

Status Offense 

 (1) is without proper care or control 
 (2) has been placed for care or adoption in violation of law 
 (3) has been abandoned  
 (4) is without a parent, guardian, or legal custodian    
 (10) is born to a parent whose parental rights with regard to 

another child have been involuntarily terminated  
Abuse: 

 The petition alleges that the above named child is a victim of child 

abuse as defined at 23 Pa.C.S. §6303. 

 (5)  while subject to compulsory school attendance is habitually and 

without justification truant from school  

 (6) has committed a specific act or acts of habitual disobedience   
 (7) is under the age of ten years and has committed a delinquent act   
 (8)  has been formerly adjudicated dependent, and is under the 

jurisdiction of the court 

 (9) has been referred pursuant to section 6323 (relating to informal 
adjustment), and who commits an act which is defined as ungovernable 
in paragraph (6)  

Protective Custody: 

 Child is NOT in Protective Custody 
Location of the child is:            
 Child remains in home but is in imminent risk of placement 
in foster care absent preventive services. 

under supervision of the county agency 
Date:                              Time:            
Location of the child is:            

 Child is in Protective Custody (removed from the home) and 

CHILD’S PARENTS AND/OR OTHER LEGAL GUARDIAN OR CUSTODIAN 

Mother’s Name:  
           
DOB:            

Father’s Name: 
           
DOB:            

Address:            
           
           
Phone Number(s):  Phone Type: 
           
           
           

Address:            
           
           
Phone Number(s):  Phone Type: 
           
           
           

           
           
           
   Whereabouts Unknown 
  Closest Relative – If whereabouts unknown for Parents and Guardian 
Name:            
Address:            
Phone Number:            
Relation to Child:            

           
           
           
   Whereabouts Unknown 

Legal Guardian’s or Custodian’s Name: 
           
Relationship:                        DOB:            
Address:            
           
           
Phone Number(s):  Phone Type: 
           
           
           

           
           
           
   Whereabouts Unknown 

  Additional Participants with Relationship to Child 

(see attached) 

CHILD’S ATTORNEY/GUARDIAN AD LITEM 

Attorney’s Name:            

Address:            
           
Supreme Court ID:            

Guardian Ad Litem’s Name:            

Address:            
           
Supreme Court ID:            

AOPC Form Updated Rev 8/2/2010                                                 

 

Petition/Application Cover, Page 1 of 2 

 

 

 

 
ADDITIONAL PARTICIPANTS WITH RELATIONSHIP TO CHILD  

In the Interest Of: 
______________________, a Minor 

Name 

DOB 

Relationship to Child 

Address 
(Indicate if Whereabouts 
Unknown) 

Phone 
(indicate type  
ex: Cell Phone) 

           

           

           

           

           

           

           

           
 

   

           
 

           

           

           

           

           

           

           

           

           

           

           

           

           

           

           

           

           

           

           

           

           

           

           

           

           

           

           

           

           

           

           

 

 

   

   

   

   

   

   

   

   

AOPC Form Updated Rev 8/30/2010                                              

 

Petition/Application Cover, Page 2 of 2

Commonwealth of Pennsylvania

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Pennsylvania state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.pacourts.us (2023-03)
Page(s): 2
Fields(s): 136
Average fields per page: 68
Reading Level: Grade 10
LIST Grouping(s): FA-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Commonwealth of Pennsylvania

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02