IN THE COURT OF COMMON PLEAS 

(FAMILY COURT DIVISION in Philadelphia County) 

Docket No.: CP- 

-DP-

   - 

In the Interest  
of _____________________, a Minor 

  [Initials of Minor]  

Date of Birth _____________ 

TO CLERK OF 

     : 
1
[Title of Clerk Maintaining Dependency Docket] 

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

I hereby notify you that the following has been filed on ______________________  with the 

[DATE OF FILING]

Orphans’ Court in _________________________ County concerning the above-child: 

[NAME]

 A petition to relinquish parental rights of _________________________. 

[INITIALS OF PARENT(S) NAMED IN PETITION]

 A petition to terminate parental rights of __________________________. 

[INITIALS OF PARENT(S) NAMED IN PETITION]

 A petition to confirm consent of __________________________. 

[INITIALS OF PARENT(S) NAMED IN PETITION]

A petition for adoption.  

Date: ________________ 

__________________________ 
On behalf of:      

______________________________________________

District 

1In the First Judicial 
Family Court division; 
be personnel 
he other counties, the Clerk will be the Clerk of the Juvenile 
t

County), 
(i.e., 
of Records for the Civil/Family 

this Clerk will be the Clerk of the
this Clerk will 
County), 
Allegheny 
and in most 
 
division;
Court division. 

Philadelphia 
District 

at the Department 

in the Fifth Judicial 

(i.e., 

of 

Form A-01 Rev. 7/1/2022