DEPENDENCY PETITION 

In the Interest Of: 
______________________, a Minor 

To the Honorable Judge of said Court: 

The petitioner respectfully  represents that the above mentioned child is a DEPENDENT CHILD, as defined by 

The Juvenile Act at 42 Pa.C.S.§ 6302.  It is within the jurisdiction of the Court and in the best interests of said 

child and the public that this proceeding be brought before the Court for the following reasons:  

The child: 

1) is without proper parental care or control, subsistence, education as required by law, or other care or
control necessary for his/her physical, mental, or emotional health, or morals; a determination that there is a 
lack of proper parental care or control may be based upon evidence of conduct by the parent, guardian or 
custodian that places the health, safety or welfare of the child at risk, including evidence of the parent’s, 
guardian’s or other custodian’s use of alcohol or a controlled substance that places the health, safety or 
welfare of the child at risk; 

2) has been placed for care or adoption in violation of law;

3) has been abandoned by his/her parents, guardian or other custodian;

4) is without a parent, guardian or other custodian;

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 of the reasonable and lawful commands

of his/her parent, guardian, or other custodian and who is ungovernable and found to be in need of care, 
treatment or supervision;  

7) is under the age of ten and has committed a delinquent act;

8) has been formerly adjudicated dependent, and who is under the jurisdiction of the court, subject to its

conditions or placements and who commits an act which is defined as ungovernable; or 

9) has been referred pursuant to an informal adjustment and who commits an act which is defined as

ungovernable; 

10) is born to a parent whose parental rights with regard to another child have been involuntarily
terminated under 23 Pa.C.S. § 2511 (relating to grounds for involuntary termination) within three years 
immediately preceding the date of birth of the child and conduct of the parent poses a risk to the health, 
safety or welfare of the child. 

Specifically, on or about (date or time period): 
(State the facts supporting the allegations. Attach additional pages if necessary.) 

 Additional pages attached. 

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 Dependency Petition, Page 1 of 4 

 Motion for Finding of Aggravated Circumstances Attached 

 The petitioner alleges that the child is a victim of child abuse as defined at 23 Pa.C.S. §6303, in that: 
(Specify where the abuse occurred, nature and extent of the abuse, name and relationships of the persons responsible for causing the 
abuse and any evidence of prior abuse by those persons.)

DEPENDENCY PETITION 

 The petitioner avers that it would be contrary to the welfare, safety and health of the child to remain under the 

care of          

 The petitioner avers that reasonable efforts were made to prevent the placement of the Child. The following 

efforts were made to prevent the placement of the child: 

 Additional pages attached. 

 The petitioner avers that preventive services were not offered due to the necessity for emergency placement. 
The  lack  of  services  was  reasonable  under  the  circumstances.  This  level  of  effort  was  reasonable  due  to  the 
emergency nature of the situation, safety considerations, and circumstances of the family. 

 The petitioner avers that there are no less restrictive alternatives available, because: 

 The petitioner avers that the following family finding efforts were made: 

 The petitioner avers that the following family members were contacted: 

 The anticipated placement of the Child is:  

 The Agency has determined it would pose a risk to the safety of the Child or guardian to release the current 

whereabouts of the Child. 

Wherefore, your petitioner prays this Honorable Court to fix a hearing to inquire into the matters alleged 

concerning the above named child and to make such order as deemed appropriate.  If said child is found to be a 

dependent child and the Court determines that aggravated circumstances exist, your petitioner prays your 

Honorable Court to determine whether reasonable efforts to preserve and reunify the family shall be made or 

continue to be made and schedule any permanency hearing that may be required. 

Further, if the child is found to be dependent and is to enter placement or commitment, or otherwise be removed 

from the child’s home at disposition, the petitioner seeks the Court to enter such order of disposition, to 

determine that to allow the child to remain in the home would be contrary to the welfare of the child; to 

determine whether reasonable efforts were made to prevent such removal of the child from the child’s home; or 

if preventive services were not offered due to the emergency nature of the situation, safety considerations, and 

circumstances of the family, whether this level of effort was reasonable. 

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Dependency Petition, Page 2 of 4 

If the Court determines, pursuant to 42 Pa.C.S. § 6332, that reasonable efforts were not made to prevent the 

initial removal of the child from the child’s home, your petitioner prays your Honorable Court to determine, prior 

to entering an order of disposition under 42 Pa.C.S. § 6351, whether additional information is now available that 

would allow for a finding that such efforts were reasonable or whether reasonable efforts are underway to make 

it possible for the child to return home.  

DEPENDENCY PETITION 

The Petitioner verifies and acknowledges that the facts set forth in the petition are true and correct to the 

petitioner’s personal knowledge, information, or belief, and that any false statements are subject to 

penalties of the Crimes Code, 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities. 

PETITIONER NAME/TITLE 

ATTORNEY NAME 

PETITIONER SIGNATURE 

ATTORNEY SIGNATURE 

DATE 

DATE 

Adjudicatory Hearing Request: ________________________________________ 

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Dependency Petition, Page 3 of 4 

DEPENDENCY PETITION 

In the Interest Of: 
______________________, a Minor 

(Continuation of the facts supporting the allegations.) 

ALLEGATIONS OF DEPENDENCY 

AOPC Form Updated 9/29/2015  

Dependency Petition, Page 4 of 4