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Court

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Case No._____________________
not established

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CO

AOC-DNA-1
Rev. 1-11
Page 1 of 2
Commonwealth of Kentucky
Court of Justice www.courts.ky.gov
KRS 610.010, 620.023, .027, .050,
.060, .070, .080; FCRPP 20

OF JUS

JUVENILE
DEPENDENCY, NEGLECT AND ABUSE
PETITION

Dec 12, 2001

Hearing Date __________________,
2______

[ ]

District [ ] Family

Christian
County_______________________
Division ______________________
D

CLERKS USE ONLY

9:00
Hearing Time ______________
[] a.m. [ ] p.m.

Hearing Location ____________________________________________________________________________

Christian County Court House rm3
__________________________________________________________________________________________

Payton Grace Arwine

IN THE INTEREST OF: ____________________________________________________________________,
A CHILD
Birthdate

Sex

Race

12/03/2010

SSN
000-00-0000

Jessica Carroll
Afant, __________________________________________________________________________________,
Christian
2
says that on September
________________, 2_____,
in _______________________
County, Kentucky, the above-named juvenile
was/is [ ] dependent (UOR Code - 002813) [ ] neglected (UOR Code - 002814) [] abused (UOR Code - 002815)
pursuant to KRS Chapter 620 et seq and within the scope of KRS 610.010(2)(d); Afants grounds of belief are: ______
_______________________________________________________________________________________________
Parent of above mentioned child has no livable dwelling to provide a safe, secure, and stable living environment for her
minor child. Also affiant alleges that the mother of this child is involved in a sexual relationship with a registered sex
_______________________________________________________________________________________________
offender who is often left alone with the child. Also affiant states that child's father is iincarcerated and that the mother
_______________________________________________________________________________________________
is involved in several illegal activities, including illicit drug use and theft.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

Chelsea Dawn Wyatt Arwine

Name of person believed responsible for neglect and/or abuse _________________________________________
Juveniles Address:
_______________________________________________________________________________________________
Unestablished
_______________________________________________________________________________________________
Cerulean
Kentucky
42213
(270) 498-0895
________________________________________________________________
Telephone No. __________________
not enrolled/infant
Juvenile attends school at __________________________________________________________________________
Jessica Carroll
Afants Name (print) _____________________________________________________________________________
500 Richard Street
Afants Address _________________________________________________________________________________
_______________________________________________________________________________________________
Hopkinsville
Kentucky
42240
_______________________________________________________________________________________________
Telephone No. _____________________
(270) 987-2595
Distribution: Court File
Local DCBS

Parent or other person exercising custodial control or supervision (sheriff to serve)

Local CASA Project Director upon Court referral

AOC-DNA-1
Rev. 1-11
Page 2 of 2

Case No. ___________________

not established

Chelsea Dawn Arwine

Juveniles Legal Mother: _______________________________________________________________
no livable address
Address: _____________________________________________________________________________
_____________________________________________________________________________________
Cerulean
Kentucky
42213
_____________________________________________________________________________________
Phone No. _________________
SSN _____________________ Legal Custodian? [ ] Yes [ ] No
(270) 498-0895
Name of Other(s) Living in Mothers Home and relationship to Child:
[ ] Stepfather ________________________________________________________________________
[ ] Sibling(s) ________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
[ ] Other ___________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

David Jack Arwine

Juveniles Legal Father: _______________________________________________________________
410 W. 7th Street (County Jail Inmate)
Address: _____________________________________________________________________________
_____________________________________________________________________________________
Hopkinsville
42240
Kentucky
_____________________________________________________________________________________
Phone No. _________________ SSN _____________________ Legal Custodian? [ ] Yes [ ] No
Name of Other(s) Living in Fathers Home and relationship to Child:
[ ] Stepmother _______________________________________________________________________
[ ] Sibling(s) ________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
[ ] Other ___________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
N/A
[ ] Name and relation of other person exercising custody or control of child _____________________________
_____________________________________________________________________________________________
[

] Name and address of nearest known adult relative if no parent or person exercising custodial control or

supervision (PECC) is located:

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Afant states the foregoing allegations are true based upon information and belief.
Afants Signature ______________________________________________________________________________
Sworn to before me on ___________________, 2_____. My Commission expires: _________________, 2_____.
______________________________________________ Name
______________________________________________ Title