NOTICE/SUMMONS AND ORDER FOR HEARING - TERMINATION OF PARENTAL RIGHTS JD-JM-40 Rev. 6-13 C.G.S. §§ 45a-716, 46b-123d; P.A. 11-51, Sec. 19; PA 11-240, Sec. 2; Pr. Bk. Secs. 32a-1(g) 33a-2(b), (c), 33a-4 and 33a-5 STATE OF CONNECTICUT SUPERIOR COURT Instructions to Clerk 1. Set matter down for hearing not more than 30 days after petition is filed, except not more than 20 days after a consent petition is filed. 2. Fill in name and telephone number of clerk in "Notice to Person(s)..." JUVENILE MATTERS www.jud.ct.gov Superior Court for juvenile matters at (Address of Court) In the interest of (Name of child/youth) Summons/Order For Hearing And Notice The attached petition for termination of parental rights in the interest of the minor child or youth named above has been presented to the court. It is ordered: A hearing on this matter is scheduled for: 1. that the following persons are summoned come to Time (A.M/P.M.) X Date court at the above address on 2. that any proper officer make due and legal service of the order and summons and the foregoing petition at least ten (10) days before the above hearing date as follows: By personal service, having a true and attested copy of the petition and this order left with and in the hands of: Name and Address 1. 2. By abode service, leaving a true and attested copy of the petition and this order at the usual place of abode: Name and Address 1. 2. By certified mail, restricted delivery, return receipt requested, addressed to: Name and Address 1. 2. By Publication In (Name(s) and location(s) of newspaper(s)) To Give Notice To (Name and last known address) 1. 2. Date at (Town) On (Date) By order of the court (Name of Judge) Signed (Clerk) Notice To Person(s) Whose Parental Rights Are Sought To Be Terminated 1. Failure to appear: If you do not come to court, the court may take action against you including entering orders affecting your parental rights. 2. Right to counsel: You have a right to be represented by an attorney. If you want an attorney but cannot pay for one and if you give proof that you cannot pay, the court will make sure that the Chief Public Defender assigns an attorney to you. Your request for an attorney should be made immediately by filling out the JD-JM-114 Application for Appointment of Counsel/Waiver of Fees form. Submit the application form in person, by mail or fax at the court location where your hearing is going to be held. 3. Effects of a termination decree: The termination decree will be the complete end of the legal relationship between the child or youth and the person(s) whose parental rights have been terminated so that the child or youth is free for adoption except it shall not affect the right of inheritance of the child or youth or the religious affiliation of the child or youth. The parent will have no legal right or responsibility to care for the child or youth or make any decisions on behalf of the child or youth, to obtain the child's or youth's birth certificate or any state or federal benefit. The parent will have no legal responsibility to support or to pay for the child's or youth's expenses after the effective date of termination. The child or youth will be legally free for adoption after the termination and the parent will have no right to notice of the adoption proceedings nor any right to participate in the proceedings. 4. Right to remain silent: You have the right to refuse to make any statements; any statements you make may be introduced in evidence and used against you. Name of Clerk Telephone number Fax number The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation under the ADA, contact the court clerk at the number listed above or an ADA contact person listed at www.jud.ct.gov/ADA. Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Return of Service - To be completed by any proper officer STATE OF CONNECTICUT County of SS. Name of person(s) served Docket number Date of service Fees Then and there, I duly served the foregoing petition, order and summons on the above-named respondent(s), by either (check one): leaving with (for in hand); or leaving at the usual place of abode (for abode) at___________________________________________________________________________ The within and foregoing is a true and attested copy of the original petition, order, and summons. Attest (Signature and title of proper officer) Copy Endorsement Service Travel Total STATE OF CONNECTICUT County of SS. Name of person(s) served Date of service Fees Then and there, I duly served the foregoing petition, order and summons on the above-named respondent(s), by either (check one): leaving with (for in hand); or leaving at the usual place of abode (for abode) at___________________________________________________________________________ The within and foregoing is a true and attested copy of the original petition, order, and summons. Attest (Signature and title of proper officer) Copy Endorsement Service Travel Total STATE OF CONNECTICUT County of SS. Name of person(s) served Date of service Fees Copy Then and there, I duly served the foregoing petition, order and summons on the above-named respondent(s), by either (check one): leaving with (for in hand); or leaving at the usual place of abode (for abode) at___________________________________________________________________________ The within and foregoing is a true and attested copy of the original petition, order, and summons. Attest (Signature and title of proper officer) Endorsement Service Travel Total For Mail Service STATE OF CONNECTICUT County of SS. United States Port Office at (Town) Date of service Then and there, by virtue hereof, I made service of the within petition, order and summons by depositing a true and attested copy by United States Post mail, postage prepaid, addressed to ______________________________________________________________, by (check one): restricted delivery, return receipt requested; or first class mail; or certified mail, return receipt requested. The within and foregoing is the original petition, order and summons with my doings thereon endorsed. Attest (Signature and title of proper officer) Fees Copy Endorsement Service Travel Total JD-JM-40 Rev. 6-13 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com PETITION FOR TERMINATION OF PARENTAL RIGHTS C.G.S. §§ 17a-111b, 17a-112, 45a-715, 45a-717 Pr. Bk. Sec. 33a-1 STATE OF CONNECTICUT SUPERIOR