VERIFIED PETITION FOR VISITATION -- GRANDPARENTS & THIRD PARTIES JD-FM-221 Rev. 12-14 C.G.S. §§ 46b-56, 46b-59 P.B. §§ 25-4, 25-5 STATE OF CONNECTICUT Court use only PETVIS SUPERIOR COURT www.jud.ct.gov *PETVIS* Instructions: Attach Order to Attend Hearing (JD-FM-162), and Affidavit Concerning Children (JD-FM-164). If you are a parent of the child or children, use the Custody/Visitation Application -- Parent (JD-FM-161). Docket number Judicial District of At (Town) Petitioner's name (Last, first, middle initial) Respondent's name (Last, first, middle initial) Additional respondent's name (If applicable) 1. I am the child(ren)'s Grandparent Mother Other (Specify): Father Grandparent Other: 2. The respondent(s) is/are the: 3. I want visitation rights with the child(ren) listed below: Child's name (First, middle, last) Date of birth Name(s) of parent(s) or guardian(s) (First, middle initial, last) (Attach additional sheets if necessary) 4. Connecticut has the authority to decide this case and should decide this case because: ("x" all that apply) a. b. c. d. e. f. Connecticut is the home state of the child(ren) at the time of the filing of this case. The child(ren) has or have lived in Connecticut for the past 6 months, or from birth if the child(ren) is or are younger than 6 months old. The child(ren) lived in Connecticut for at least 6 months but was or were taken from Connecticut less than 6 months ago by a person claiming custody, and a parent or guardian continues to live here. The child(ren) and at least 1 parent have a significant connection to Connecticut and there is substantial evidence in Connecticut concerning the child(ren)'s present or future care, protection, training and personal relationships. The child(ren) is or are in Connecticut now and has or have been abandoned or there is an emergency affecting the child(ren)'s well-being. No other state has an interest in hearing this case and it is in the best interest of the child(ren) for a Connecticut court to hear the case. I have a relationship with the child(ren) that is parent-like. (State specifically how your relationship is parent-like): 5. 6. Denial of visitation will cause real and significant harm to the child(ren). (State specifically what harm would be caused to the child(ren) by a denial of visitation): JD-FM-221 Rev. 12-14 (Page 1 of 2) (Continued on Page 2) American LegalNet, Inc. www.FormsWorkFlow.com Claim For Relief The Petitioner asks the Court for: Visitation as follows: Upon motion, the court may order the payment of fees for another party, the attorney for the minor child, the guardian ad litem, or any expert by any party in accordance with such party's financial ability. Signature of Petitioner Address Print name of person signing at left Date signed Telephone (Area code first) Verification I declare under penalty of perjury that this Petition for Visitation is true and correct. Signed (Petitioner) Subscribed and sworn to before me: Signed (Clerk, Notary, Commissioner of Superior Court Date signed 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. JD-FM-221 Rev. 12-14 (Page 2 of 2) American LegalNet, Inc. www.FormsWorkFlow.com