STATE OF CONNECTICUT REVOCATION OF ORDER OF COMMITMENT/GUARDIANSHIP CUSTODY/TEMPORARY CUSTODY AND SUBSEQUENT ORDER OF CUSTODY/TEMPORARY CUSTODY GUARDIANSHIP/PROTECTIVE SUPERVISION JD-JM-76 Rev. 4-12 C.G.S. § 46b-129(m) P.B. §§ 26-1(q), 35a-12, 35a-14a, 35a-16 SUPERIOR COURT JUVENILE MATTERS www.jud.ct.gov ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. Docket Number Juvenile Matters At (Address of court) Name of Minor Child or Youth Date of Birth Place of Birth Name of Mother Address of Mother Name of Father Address of Father Name of Guardian (If applicable) Address of Guardian (If applicable) Order of Custody/Guardianship The court enters the following orders in the best interest of the child or youth named above at a session of the Superior Court and in accordance with the statutes that apply to the case: 1. Temporary custody is vested in: Name (Other than Commissioner of DCF) Relationship to Child or Youth (if any) Address 2. The order of Commitment and/or Custody Temporary Custody to Guardianship entered on with respect to the minor child or youth named above is revoked or modified and the child's or youth's: Custody Guardianship Temporary Custody Reverts To: Is Transferred To: Is vacated Name (Other than Commissioner of DCF) Relationship to Child or Youth (If any) Address 3. Protective Supervision is ordered, beginning until The child or youth is to reside with the custodian and/or guardian named above subject to the services and steps set out in the Specific Steps. Dated At (Town) On (Date) By (Type name of Judge) Signed (Judge/Clerk) Distribution: Original - File Copy 1 - Parent or Guardian Copy 2 - Commissioner of D.C.F. American LegalNet, Inc. www.FormsWorkFlow.com