(Page 1 of 2)INTERSTATE COMPACT FOR JUVENILES TAKE INTO CUSTODY APPLICATION AND ORDER NON-DELINQUENT RUNAWAY JD-JM-193 Rev. 6-19 C.G.S. 247247 46b-120, 46b-133, 46b-149(f), 46b-51h P.B. 247 31a-13A Address of Court Docket number Name of child Address of child Date of birth Date of petition Name, address and title of applicant AffidavitI certify that the following statements are true and accurate to the best of my knowledge and belief.The child named above is a resident of the State ofBased on this information and the belief that it is in the best interests of the child that the child be taken into custody to be presented before a judge of the Superior Court Juvenile Matters for proceedings as provided by the terms of the Interstate Compact For Juveniles, I request that the court issue a Take Into Custody Order and that the child be taken into custody and brought immediately before a judge of the Superior Court Juvenile Matters. If court is not in session, then I request that the child be placed in a staff secure facility pending a hearing on the next court date.* This affidavit is made voluntarily, knowing that it may result in the apprehension and return of the child after a hearing to the child's home state and affirm that it is true to the best of my knowledge and belief.from home or other lawful place of abode in that State and is believed to be located at within the State of Connecticut. The State ofhas indicated that it will be responsible forthe reasonable expenses relating to the child's return to that state.The affiant bases this information and belief on the following documents that are incorporated and made part of this application: (check all that apply)and has been reported to be a runaway Requisition issued through the Interstate Compact For Juveniles; Affidavit from parent/guardian/court officer; Court Order; Verified NCIC communication; Other (specify); Signed (Police officer/juvenile probation officer/prosecutorial official) Signed (Judge/Clerk/Commissioner of Superior Court/Notary) Print/type name of person signing Signed at (Town) On (Date) Subscribed and sworn to before me At (Town) On (Date) *NOTE:240Non-delinquent runaways from out of state are not to be placed in a juvenile detention center.240(Section 46b-149(f) of the Connecticut General Statutes).240To comply with Rule 6-102 of the Interstate Compact For Juveniles, the holding state may hold non-delinquent runaways from out of state in a location it deems appropriate pending return. For the police officer, probation officer or prosecutorial official: Contact the appropriate Program and Services Supervisor at (860) 214-4137 or (959) 333-7913 to arrange for placement in a Community Residential Program. If the appropriate Community Residential Program cannot take the child, contact the DCF Careline at 1-800-842-2288 to arrange for placement at a suitable alternative facility. STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov American LegalNet, Inc. www.FormsWorkFlow.com (Page 2 of 2)JD-JM-193 Rev 5-19I have reviewed this Application, affidavit(s) and other supporting documents and find that there is probable cause to believe that the child has unlawfully left the child's home state or lawful place of abode in violation of the laws of the child's home state or the orders of the court in the child's case, that there is a need to hold the child for the child's return to the child's home state, that there is no less restrictive alternative available and that it is in the child's best interests to be taken into custody and presented before a judge of the Superior Court Juvenile Matters for further proceedings on the request to return the child to the child's home state. I also find that the State of will be responsible for the reasonable expenses relating to the child's return to that state.FindingTake Into Custody OrderTo: Any Proper Officer of the State of Connecticut By Authority of the State of Connecticut, you are commanded to take the child named in this application into custody and present the child immediately before a judge of the Superior Court Juvenile Matters. If court is not in session, then the child is to be placed in the designated Community Residential Program pending a hearing on the next court date. Date (Month, day, year) Date, Time and Signature At (Time, A.M. or P.M.) Signed (A judge of the Superior Court)Return On Take Into Custody Order Town of Date State of ConnecticutThen and there, by virtue of the within and foregoing affidavit/warrant, I took the child named in this application into custody and have executed the issuance of the Take Into Custody Order on the named child pursuant to the order of the Court and (check one): Brought the child to the Superior Court Juvenile Matters at for presentment before said court. Placed the child in the staff secure facility located at to be held pending presentment before a judge of the Superior Court. Attest (Officer's signature and department) American LegalNet, Inc. www.FormsWorkFlow.com