(Page 1 of 2)INTERSTATE COMPACT FOR JUVENILES TAKE INTO CUSTODY APPLICATION AND ORDER DELINQUENT CHILD JD-JM-192 Rev. 7-18 C.G.S. 247247 46b-120, 46b-133, 46b-140a, 46b-151h; P.A. 18-31; P.B. 247 31a-13STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Address of court Docket number Name of child Date of birth Address of child Date of petition Name, address and title of applicantAffidavitI 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 ofand has been designated by the child's home state as: An alleged delinquent child who is wanted pursuant to an arrest warrant or other order to be taken into custody; An alleged delinquent child who has been arrested but not yet adjudicated; An adjudicated delinquent, pending disposition; A child who is on probation; A child who has escaped from custody; A child who is under a delinquency commitment in another state; Other (specify); The child is reported to have unlawfully left the jurisdiction of the child's home state or other lawful place of abode and is believed to be located at in the State of Connecticut. The State of has indicated that it will be responsible for the 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) Requisition issued through the Interstate Compact For Juveniles; Affidavit from probation officer or parole officer or court officer; Arrest Warrant; Court Order; Verified NCIC communication; Other (specify); Based 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 the child is to be placed in the juvenile detention facility located at pending a hearing on the next court day. This affidavit is made voluntarily, knowing that it may result in the apprehension, detention 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. Signed (Police officer/juvenile probation officer/prosecutorial official) Print/type name of person signing Signed at (Town) On (Date) Subscribed and sworn to before me Signed (Judge/Clerk/Commissioner of Superior Court/Notary) At (Town) On (Date) American LegalNet, Inc. www.FormsWorkFlow.com (Page 2 of 2)JD-JM-192 Rev. 7-12FindingI 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.Take 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 juvenile detention facility located at pending a hearing on the next court date. Said child is ordered not to be released by the Juvenile Detention Superintendent or designee. Date, Time and Signature Date (Month, day, year) 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 juvenile detention 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