MOTION FOR INTERVENTION IN FAMILY MATTERS JD-FM-185 Rev. 10-10 C.G.S. § 46b-57 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov COURT USE ONLY MTI Instructions Fill out the form below to intervene in an existing case and file it with the Court Clerk. You must also file an Appearance form (JD-CL-12). At (Town) Docket number *MTI* Judicial District of Name of case Intervenor's name (Last, first, middle initial) Return date (Month, day, year) (if applicable) Intervenor's address (Number, street, town, state, zip code) 1. I am the (State relationship to child(ren), for example grandparent, aunt, uncle, etc.): 2. I have a relationship with the child(ren) that is similar in nature to a parent-child relationship. (State specifically how your relationship is similar to a parent-child relationship): (Check if asking for visitation) Denial of visitation will cause real and significant harm to the child(ren). (State specifically what harm would be caused to the child(ren)): Or (Check if asking for custody) Parental custody clearly is detrimental to the child(ren) and giving me custody would be in the child(ren)'s best interests. custody of the child(ren) listed below 3. I want ("X" one): Child's Name (First, middle, last) Child's Age visitation rights with the child(ren) listed below Name(s) Of Parent(s) Or Guardian(s) (First, middle initial, last) "X" here if additional children are listed on a separate sheet. 4. Briefly explain why you are asking to intervene in this case: I request the Court's permission to intervene in this case. I certify that a copy of the above was mailed/delivered to all counsel and self-represented parties of record on: Signed (Attorney or self-represented party) Address (Number, street, town and zip code) Address that copy was mailed or delivered to:* Date mailed or delivered Name of each party that copy was mailed or delivered to:* *If necessary, attach additional sheet with name and address of each party the form was mailed or delivered to. Print Form Reset Form American LegalNet, Inc. www.FormsWorkFlow.com Order (To be completed by the court) The court has heard this motion and orders it: This Court further orders the appointment of Attorney Granted Denied of as counsel for the child(ren) in this case under the provisions of section 46b-54 of the Connecticut General Statutes. By the Court (Name of Judge) Signed (Judge/Assistant Clerk) Print name of person signing at left Date signed , J. JD-FM-185 Rev. 10-10 (Page 2/Back) Print Form Reset Form American LegalNet, Inc. www.FormsWorkFlow.com