AOC- 034
Doc. Code: PIDMD
Case No. ____________________
Rev. 6-11
Page 1 of 1
l e x
e t
Court _______________________
j u s t i t i a
Commonwealth of Kentucky
County ______________________
Court of Justice
personal identifier data sheet
(Mental Health / Disability / Incompetency)
****For use in actions brought or proceedings conducted pursuant to KRS Chapters 202A (Involuntary hospitalization
of the mentally ill); 202B (Involuntary mental retardation admission); 222.430 et seq. (Involuntary treatment for alcohol
and other drug abuse); 387.500 et seq. (Guardianship and conservatorship for disabled persons); 504 (Responsibility,
incompetency/insanity/mental illness); and, 645 (Involuntary hospitalization of the mentally ill child).
TO THE PETITIONER IN A MENTAL HEALTH OR DISABILITY PROCEEDING
TO THE DEFENDANT OR HIS/HER ATTORNEY IN A CHAPTER 504 PROCEEDING
The Court requires that you provide the following information about the Respondent/Defendant in this case:
RESPONDENT/DEFENDANT:
Please Print
First
Middle
Last
Also known as: __________________________________________________________________________________
Street address: __________________________________________________________________________________
Mailing address: _________________________________________________________________________________
Respondent's/Defendant's Identifiers:
Sex
Race
Date of Birth
Height
Weight
Eyes
Hair
Social Security #
Drivers License #
State
I understand that the information requested herein is intended to be entered into the official court record of this matter,
and that its accuracy is of the utmost importance. The information I have provided above is true and accurate to the best
of my knowledge and belief.
____________________________________, 2______
____________________________________________
Date
(Signature)
___________________________________________
(Printed Name)
Original: Court file
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