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 

     : 

       [Title of Clerk Maintaining Dependency Docket]1

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]

An order    granting   denying (circle one)  the petition to relinquish parental rights 
of  _________________________.  
[INITIALS OF PARENT(S) NAMED IN PETITION]

  

An order    granting   denying (circle one)  the petition to terminate parental rights 
of  _________________________. 

[INITIALS OF PARENT(S) NAMED IN PETITION]

An order    granting   denying (circle one) the petition to confirm consent of  
________________________.   

[INITIALS OF PARENT(S) NAMED IN PETITION]

 With the above-order relinquishing or terminating parental rights or confirming the 
 consent of the parent(s), the child is available for adoption.       

Do not check if at least one parent still has parental rights. 

An order    granting   denying (circle one) the petition for adoption. 

Date: _________________ 

__________________________ 
On behalf of:        

______________________________________________

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

of Records for the Civil/Family 

n the Fifth Judicial District 
i

at the Department 

Allegheny County), 

(i.e., 

(i.e., 

Philadelphia County), this Clerk will be the Clerk of 

division; and in most of the 

the

e 

this Clerk will b

Form A-02 Rev. 7/1/2022