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  the  appeal  from  the  Orphans’  Court  order  concerning  the  above-child  has 
been disposed on __________________ in the following manner: 

 Quashed 

 Affirmed 

 Reversed 

 Vacated & Remanded 

   Other: _________________________________________________________________ 

Date: ____________________ 

__________________________ 
On behalf of:  

AOPC Form Rev. 4/18/13



(Untitled)

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