JD-JM-58 Rev. 12-15 C.G.S. § 46b-129(b) & (k), P.A. 09-185, Sec. 3, P.B. 33a-6 Address of Court Name of Child/Youth Address of Child/Youth MOTION/ORDER OF TEMPORARY CUSTODY/ORDER TO APPEAR STATE OF CONNECTICUT SUPERIOR COURT JUVENILE MATTERS www.jud.ct.gov Docket Number Date of Birth Date of birth Date of birth Date of birth Date of birth Indian tribe/reservation Indian tribe/reservation Indian tribe/reservation Indian tribe/reservation Name, address, and type (if applicable) (mother, father, guardian, putative father) Name, address, and type (if applicable) (mother, father, guardian, putative father) Name, address, and type (if applicable) (mother, father, guardian, putative father) Name, address, and type (if applicable) (mother, father, guardian, putative father) If parent(s) is/are minor(s), name(s) and address(es) of grandparent(s) or guardian(s): Motion The child or youth has been placed in the care and custody of the Commissioner of Children and Families pursuant to . at (time) section 17a-101g (96 hour hold) on (date) Based on the allegations of the petition and verified affirmations of fact, the petitioner requests an ex parte Order of Temporary Custody/Order to Appear under section 46b-129(b) of the general statutes. Name of Petitioner Signed (Petitioner) Address of Petitioner Subscribed and sworn to before me on (Date) Relationship to Child Signed (Judge, Assistant Clerk, Notary, Comm. Superior Court) Order The court having reviewed the verified affirmations of fact accompanying this motion hereby finds that there is reasonable cause to believe that: A. Said child or youth is suffering from serious physical illness, or B. Said child or youth is suffering from serious physical injury, or C. Said child or youth is in immediate physical danger from surroundings; And As a result of said conditions, the child's or youth's safety is endangered and immediate removal from such surroundings is necessary to ensure the child's or youth's safety and continuation in the home is contrary to the welfare of said child or youth. It is Hereby Ordered That: The temporary care and custody of said child or youth shall be vested in: A. pending a hearing as set forth below on the confirmation of this order; And it is further found that: Reasonable efforts to prevent or eliminate the need for removal of said child or youth were made by the state, or Reasonable efforts to prevent or eliminate the need for removal of said child or youth were not possible, or Reasonable efforts to prevent removal were not made. OR B. The respondent(s) appear before the court as set forth below to determine whether an order vesting temporary custody of said child or youth, in a person related to the child or youth by blood or marriage or in some other person or suitable agency, should be issued pending disposition of the petition. And it is further ordered that the above-named mother/father/guardian be and hereby is/are summoned to appear before the court on the Hearing Date(s) set out below, at the address shown above, by having a proper officer leave a true and attested copy of this order and summons with them or at their usual place of abode, or if so ordered, by publication or mail and return same to the court on or before the date indicated. OR C. The motion is denied. Hearing Date - Preliminary Hearing On Temporary Custody Date Date Time of Hearing Time of Hearing .M. .M. Court Location (Number, street, and town) Statutory Mail For: Signed (Judge) Service on or Before (Date) Telephone Number Return Date Date Signed Hearing Date - Petition Court Location Publication For: Name of Judge (Continued) American LegalNet, Inc. www.FormsWorkFlow.com State of Connecticut County of SS. RETURN OF SERVICE Name of person(s) served Docket number Date of service Then and there, I duly served the foregoing petition, order and summons on the above-named respondent(s), by either (check one): leaving with (for in hand); or leaving at the usual place of abode (for abode) at ______________________________________ The within and foregoing is a true and attested copy of the original petition, order, and summons. Copy Fees Endorsement Service Travel Attest (Signature and title of proper officer) Total State of Connecticut County of SS. Name of person(s) served Date of service Then and there, I duly served the foregoing petition, order and summons on the above-named respondent(s), by either (check one): leaving with (for in hand); or leaving at the usual place of abode (for abode) at ______________________________________ The within and foregoing is a true and attested copy of the original petition, order, and summons. Copy Fees Endorsement Service Travel Attest (Signature and title of proper officer) Total State of Connecticut County of SS. Name of person(s) served Date of service Then and there, I duly served the foregoing petition, order and summons on the above-named respondent(s), by either (check one): leaving with (for in hand); or leaving at the usual place of abode (for abode) at ______________________________________ The within and foregoing is a true and attested copy of the original petition, order, and summons. Copy Fees Endorsement Service Travel Attest (Signature and title of proper officer) Total State of Connecticut County of SS. For Mail Service Name of person(s) served Date of service Then and there, by virtue hereof, I made service of the within petition, order and summons by depositing a true and attested copy by United States Post mail, postage prepaid, addressed to _________________________________________________________________, by (check one): restricted delivery, return receipt requested; or first class mail; or certified mail, return receipt requested. The within and foregoing is the original petition, order and summons with my doings thereon endorsed. Attest (Signature and title of proper officer) Copy Fees Endorsement Service Travel Total (Page 2 of 2) American LegalNet, Inc. www.FormsWorkFlow.com JD-JM-58 Rev. 12-15