Fill and Sign the Statement to Court of Permanency Hearing Report and Justia Form

STATEMENT TO THE COURT OF PERMANENCY HEARING REPORT AND NOTICE SENT Confidential: For Court Use Only PH-4a Page 1 of 2 PERMANENCY HEARING DATE CERTAIN: / / Judge / Referee Court Part Agency Case Manager Name Casewor ker Name Attorney for ACS/DSS IN THE MATTER OF: Child’s Name Date of Birth Sex Person ID (PID) Docket Number / / / / THE PERMANENCY HEARING REPORT AND NOTICE WAS MAILED TO: A. PARENTS Parent’s Name & Address Relationship Associated Child(ren) Date Mailed / / / / B. ATTORNEYS Attorney’s Name & Address Associated Parent Date Mailed / / / / C. CHILD’S LAW GUARDIANS Law Guardian’s Name Law Guardian Agency Name & Address Associated Child(ren) Date Mailed / / / / Confidential: For Court Use Only STATEMENT TO THE COURT OF PERMANENCY HEARING REPORT AND NOTICE SENT Confidential: For Court Use Only PH-4a Page 2 of 2 D. AUTHORIZ ED AGENCY Authoriz ed Agency Name & Address Current Associated Child(ren) Date Mailed / / / / E. FOSTER PARENTS Foster Parent’s Name & Address Current Associated Child(ren) Date Mailed / / / / F. PRE-ADOPTIVE PARENTS / RELATIVES/ OTHERS Pre-Adoptive Parent’s Name & Address Relative’s / Other’s Name & Address Current Associated Child(ren) Date Mailed / / / / THE NOTICE WAS MAILED TO: G. FORMER FOSTER PARENTS Former Foster Parent’s Name & Address Dates of Placement Associated Child(ren) Date Mailed from / / to / / / / from / / to / / / / Name: _________________________________ (print) \ Signed: _________________________________ Title: __________\ ________ Agency Name: __________________________ Agency Address: _________________________ _________________________ _________________________ Telephone Number: (______)______-________ Confidential: For Court Use Only