IN THE COURT OF COMMON PLEAS 

In the Interest  
of _____________________, a Minor 

  [Initials of Minor]  

Date of Birth _____________ 

Docket No.: CP- 

-DP-        

   - 

TO CLERK OF 

     : 

[Title of Clerk Maintaining Dependency Docket]  

Please kindly record the following in the CPCMS – Dependency Module: 

I hereby notify you that an appeal has been filed on __________________ concerning the above-child 
from the following Orphans’ Court order: 

 An order  

 granting  

 denying   the petition to relinquish parental rights of 

__________________. 

__________________. 

 An order  

 granting  

 denying   the petition to terminate parental rights of 

 An order  

 granting  

 denying   the petition to confirm consent of __________________. 

 An order 

 granting  

 denying the petition for adoption. 

Date: _______________ 

__________________________ 
On behalf of:      

AOPC Form Rev. 4/18/13



(Untitled)

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