MOTION FOR INTERVENTION IN JUVENILE MATTERS JD-JM-141 Rev. 10-12 C.G.S. �� 46b-57; 46b-129(c)(d); 46b-136; PB �� 35a-4; 35a-20; P.A. 12-1 June 12 Special Session, Secs. 272 and 273 Instructions 1. Complete the form below to intervene in an existing case and file it with the Court Clerk. 2. You must also file an Appearance form (JD-JM-13). CONNECTICUT SUPERIOR COURT JUVENILE MATTERS www.jud.ct.gov ADA NOTICE If this motion is granted, you must come to court in person, with or without counsel. Be advised Notice: that you will not be assigned an attorney at state expense unless the Judge determines that the interests of justice require such an assignment. Address of court 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. Docket number Court date and time Child's name (First, middle, last) Date of birth Name(s) of parent(s) or guardian(s) (First, middle initial, last) "X" here if additional children are listed on a separate sheet. Name of person filing this motion (Last, first, middle initial) Phone number Address of person filing this motion (Number, street, town, state, zip code) 1. I am the (State relationship to child or children): 2. I want to be made a party to this case. 3. I request the Court's permission to intervene in this case: as a sibling of a child committed to the Department of Children and Families. as a person related to the child or youth by blood or marriage. as an interested third party. 4. To be heard concerning visitation with the child or youth. 5. Only to request that the Department of Children and Families place the child or youth with me as a foster home placement. Only to seek temporary custody of the child or youth. 6. 7. Only to seek guardianship of the child or youth. 8. Only to take part in the dispositional phase of the case for the following reason other than seeking visitation, temporary custody or guardianship: 9. To request the court to modify its earlier award of guardianship. 10. To file a motion to reopen and modify the permanent legal guardianship. Signature Print name of person signing at left X I certify that a copy of this motion was mailed or delivered on parties of record. Signature (date) to all counsel and self-represented (pro se) Print name of person signing at left X Name and address of each party this motion was mailed or delivered to* *If necessary, attach an additional sheet with name of each party and the address at which the copy was mailed or delivered to. You may use form JD-CV-67. Order (To be completed by the court) The motion having been presented to, and heard by the court, it is ordered: Granted Denied The court may terminate your intervenor status if your participation in the case is no longer warranted or necessary. By the court (Name of Judge) Signed (Judge/Assistant Clerk) Print name of person signing at left Date signed , J. American LegalNet, Inc. www.FormsWorkFlow.com