APPLICATION/IMMEDIATE TEMPORARY CUSTODY PC-501 REV. 7/12 Page 1 of 3 STATE OF CONNECTICUT COURT OF PROBATE RECORDED(CONFIDENTIAL VOLUME): [Type or print in black ink. File in duplicate. ] [Complete Confidential Information Sheet for PC-501 on last page. Use Second Sheet, PC-180 , for additional data.] TO: COURT OF PROBATE, DISTRICT NO. MINOR CHILD'S BIRTH DATE IN THE MATTER OF [Name, address where residing, and zip code.] Hereinafter referred to as the minor child. TRIBE AND RESERVATION of minor child, if an Indian child as defined by P.L. 95-608, 25 U.S.C. 1901, et seq. [Name, and address] PETITIONER [Name, address, zip code, telephone number and legal status of petitioner (e.g. adult relative, counsel for minor.). If adult relative, also give date of birth. If counsel for minor, also list juris number.] PERSONS TO BE REMOVED AS GUARDIAN/TERMINATED [Name(s), address(es), zip code(s), telephone number(s), and Indian tribe and reservation if a member as defined by P.L. 95-608, 25 U.S.C. 1901 et seq. If parent, also give date of birth.] RELATIONSHIP TO MINOR CHILD Hereinafter referred to as the respondent(s) OTHER PERSON(S) WITH GUARDIANSHIP RIGHTS [Name(s), address(es), zip code(s), telephone number(s) and Indian tribe and reservation if a member as defined by P.L. 95-608, 25 U.S.C. 1901, et seq. ] MINOR CHILD IS PRESENTLY IN THE CUSTODY OF:[Name, address, zip code, and telephone number. State relationship to minor child.] THE PETITIONER REPRESENTS that: An application is pending in this court for the removal of one or both parents as guardians or for the removal of the guardian of said minor child; OR An application is pending in this court for the termination of parental rights with respect to said minor child; OR The petitioner has reasonable grounds to believe that said minor child has no guardian of his or her person. THE PETITIONER FURTHER REPRESENTS that: The minor child is in the custody of a person other than the parent or other guardian, [If this box is checked, Custodian's Affidavit, PC-510, must be filed with this application. ] AND The child was not taken or kept from the parent(s) or guardian(s), AND there is a substantial likelihood that the child will be removed from this jurisdiction prior to a hearing for temporary custody; OR To return the child to the parent(s) or guardian(s) would place the child in circumstances that would result in serious physical illness or injury, or the threat thereof, or imminent physical danger prior to a hearing for temporary custody; OR The minor child is hospitalized as a result of serious physical illness or serious physical injury and is in need of immediate medical or surgical treatment, the delay of which would be life-threatening, AND the parent(s) or guardian(s) refuses to consent or is unable to consent to such treatment. [If this box is checked, certificates from two physicians, PC-550, must be filed with this application.] OR The minor child is in the custody of the parent(s) or guardian(s), AND the minor child has suffered from serious physical illness or serious physical injury and is in need of immediate medical or surgical treatment, the delay of which would be life-threatening, AND the parent(s) or guardian(s) refuses to consent or is unable to consent to such treatment. APPLICATION/IMMEDIATE TEMPORARY CUSTODY PC-501 Page 1 of 3 Continued American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION IMMEDIATE TEMPORARY CUSTODY PC-501 REV. 7/12 Page 2 of 3 STATE OF CONNECTICUT RECORDED(CONFIDENTIAL VOLUME): COURT OF PROBATE [Type or print in black ink. File in duplicate.] THE PETITIONER FURTHER REPRESENTS that: The minor child has been abandoned by the parent or other guardian in the sense that the parent or other guardian has failed to maintain a reasonable degree of interest, concern, or responsibility for the minor's welfare; OR The minor child has been denied the care, guidance, or control necessary for physical, educational, moral, or emotional well-being as a result of acts of parental commission or omission, as defined by law. C.G.S. § 45a-610. AND THESE ACTS PLACE THE HEALTH OR WELFARE OF THE MINOR CHILD IN DANGER. THE PETITIONER ALLEGES the following specific actions, omissions, etc. that place the health or welfare of the minor child in danger. Included are dates, times, and places. [To give further details, use Second Sheet, PC-180.] THE PETITIONER FURTHER REPRESENTS that to the best of his or her knowledge and belief: The following respondent(s) is/are under a legal disability: No respondent(s) is under a legal disability. The following respondent(s) is/are in the military service of the United States or Allied Nation (Title 50 Appendix, U.S.C. 520). No respondent(s) is in the military service. There is a no proceeding pending or contemplated in Connecticut or any other state affecting the custody of the minor child. C.G.S. §§ 52-231a and 46b-115 et seq. [Complete and attach form JD-FM-164, Affidavit Concerning Children.] There has been has not been a proceeding in the past in Connecticut or any other state affecting the custody of the minor child. C.G.S. § 52-231a and 46b-115 et seq. The minor child is is not the subject of a pre-existing child support order. There is is not a current safety or service agreement between the Department of Children and Families and the parent/guardian of the minor child. There is The minor child is not a current protective order or restraining order involving any party. If so, please attach. has has not resided in Connecticut continuously for the last six months. C.G.S. § 46-115 et seq. APPLICATION/IMMEDIATE TEMPORARY CUSTODY PC-501 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION/ IMMEDIATE TEMPORARY CUSTODY PC-501 REV. 7/12 Page 3 of 3 STATE OF CONNECTICUT RECORDED(CONFIDENTIAL VOLUME): COURT OF PROBATE [Type or print in black ink. File in duplicate.] THE PETITIONER FURTHER REPRESENTS that it is in the best interest of the minor child that immediate temporary custody of the minor child be granted to a proper person as provided in C.G.S. § 45a-607, pending the determination of the aforesaid matter. WHEREFORE THE PETITIONER REQUESTS that an order for immediate temporary custody for said minor child be granted [Give relationship to minor child, if any. ] to The representations contained herein are made under the penalties of false statement. Date: ..................................................................... Petitioner: [If petitioner is requesting a waiver of fees, attach PC-184, Request/Order Waiver of Fees -- Petitioner.] PROPOSED TEMPORARY CUSTODIAN(S) IF APPOINTED, I WILL ACCEPT THE POSITION OF TRUST. Signature ......................................................................................................................................................................... Name:[Type or print.] Address and zip code: Telephone Number: Date of Birth: IF APPOINTED, I WILL ACCEPT THE POSITION OF TRUST. Signature ......................................................................................................................................................................... Name:[Type or print.] Address and zip code: Telephone Number: APPLICATION/IMMEDIATE TEMPORARY CUSTODY PC-501 Page 3 of 3 Date of Birth: American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL STATE OF CONNECTICUT DO NOT RECORD INFORMATION SHEET FOR PC-501, Application/ COURT OF PROBATE [Type or Print in Black Ink.] Immediate Temporary Custody NEW 7/12 _____________________________________________________________________________________ Court of Probate, ,District In the Matter of , a minor child. The social security numbers of the following persons are required in connection with this proceeding. 1) Petitioner who is an adult relative of the minor child: Name: Social Security Number: 2) Person(s) to be removed as guardian or whose parental rights may be terminated: a. Name: Social Security Number: b. Name: Social Security Number: 3) Proposed temporary custodian(s): a. Name: Social Security Number: b. Name: Social Security Number: American LegalNet, Inc. www.FormsWorkFlow.com