105 IN THE DISTRICT OF ________________ COUNTY, KANSAS IN THE INTEREST OF: Name __________________________________ Case No. __________________ Year of ____________ A male female □ □ APPLICATION FOR ORDER OF PROTECTIVE CUSTODY EX PARTE Pursuant to K.S.A. 38-2242 COMES NOW __________________________ County/District Attorney or designee □ other ______________________, and makes application for an Order of Protective ex parte □ Custody. The applicant believes the above-captioned child is a Child in Need of Care, and the child is likely to sustain harm if not immediately removed from the home and allowing the child to remain in the home is contrary to the welfare of the child. (Sections 1 through 6 are for use when this application is submitted to the court without a petition. They may be deleted if a petition is on file or submitted for filing with this application.) 1. CHILD: Name: Year of Birth: ____________ SSN: xxx-xx-______ Address: ☐ see cover sheet ☐ Phone: unknown 2. MOTHER: ☐ Name: Year of Birth: see cover sheet SSN: xxx-xx-______ ☐ ☐ Address: unknown see cover sheet ☐ Phone: unknown 3. FATHER: ☐ Name: Year of Birth: see cover sheet SSN: xxx-xx-______ Address: ☐ unknown ☐ see cover sheet Phone: ☐ unknown 4. CUSTODIAN (if other than a parent): Name: Address: Phone: 5. MATERNAL GRANDPARENTS: Name: Address: Phone:
105 IN THE DISTRICT OF ________________ COUNTY, KANSAS IN THE INTEREST OF: Name __________________________________ Case No. __________________ Year of ____________ A □ male □ female APPLICATION FOR EX PARTE ORDER OF PROTECTIVE CUSTODY Pursuant to K.S.A. 38-2242 COMES NOW __________________________ □ County/District Attorney or designee □ other ______________________, and makes application for an ex parte Order of Protective Custody. The applicant believes the above-captioned child is a Child in Need of Care, and the child is likely to sustain harm if not immediately removed from the home and allowing the child to remain in the home is contrary to the welfare of the child. (Sections 1 through 6 are for use when this application is submitted to the court without a petition. They may be deleted if a petition is on file or submitted for filing with this application.) 1. CHILD: Name: Year of Birth: ____________ SSN: xxx-xx-______ Address: ☐ see cover sheet Phone: ☐ unknown 2. MOTHER: Name: Year of Birth: ☐ see cover sheet SSN: xxx-xx-______ Address: ☐ unknown ☐ see cover sheet Phone: ☐ unknown 3. FATHER: Name: Year of Birth: ☐ see cover sheet SSN: xxx-xx-______ Address: ☐ unknown ☐ see cover sheet Phone: ☐ unknown 4. CUSTODIAN (if other than a parent): Name: Address: Phone: 5. MATERNAL GRANDPARENTS: Name: Address: Phone:
105%20Application%20Ex%20Parte%20Order%20Of%20Protective%20Custody%20%285-2013%29.docx