STATE OF CONNECTICUT ORDER OF TEMPORARY CUSTODY JD-JM-149 Rev. 12-08 C.G.S. § 46b-128, 46b-129(b), 46b-56(a); 17a-105 SUPERIOR COURT INSTRUCTIONS TO PREPARER JUVENILE MATTERS 1. This form is to be used only when ordering temporary custody of a minor child to the Department of Children and Families (DCF). www.jud.ct.gov 2. Upon issuance of order, contact Juvenile Court Clerk for hearing dates. 3. Provide signed original order to DCF and forward copy to Juvenile Court Clerk. 4. Retain copy of order for court file and seal document. Court Issuing Order (Location) Docket Number Name of Child/Youth Address of Child/Youth Name of Mother Address of Mother Name of Father Address of Father Name of Defendant (Criminal Matters) Address of Defendant (Criminal Matters) Name of Legal Guardian (If any) Address of Legal Guardian Name of Putative Father (If any) Address of Putative Father If Parent(s) is/are Minor(s), Name(s) of Grandparent(s) or Guardian(s) Date of Birth Address(es) of Grandparent(s) or Guardian(s) Based on the facts presented, the court makes the following findings: The defendant who resides with the above named child/youth has been charged with an offense under C.G.S. § 53-20 or 53-21 or Part V, VI, VII of Chapter 952. The custody of the above named child/youth is the subject of a pending family matter. The conditions and circumstances of the above named child/youth have been brought to the attention of this court: I. A. said child/youth is suffering from serious physical illness, or B. said child/youth is suffering from serious physical injury, or C. said child/youth is in immediate physical danger from surroundings. II. III. and As a result of said conditions, the child's/youth's safety is endangered and immediate removal from such surroundings is necessary to ensure the child's/youth's safety. Continuation in the home is contrary to the welfare of said child/youth. A. Reasonable efforts to prevent or eliminate the need for removal of said child/youth were made by the state. B. Reasonable efforts to prevent or eliminate the need for removal of said child/youth from the home were not possible. C. Reasonable efforts were not made. IT IS HEREBY ORDERED THAT: The temporary care and custody of said child/youth shall be vested in the Department of Children and Families pending a hearing as set forth below on the confirmation of this order. Date Signed Signed (Judge) Name of Judge AND IT IS FURTHER ORDERED that the above-named mother/father/guardian/defendant be and hereby is/are summoned to appear before the court on the Hearing Date(s) set out below, at the address shown below, 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. The name and address of the Victim of a sexual assault may be disclosed to DCF in accordance with C.G.S. § 54-86e. Information disclosed pursuant to this order shall not be further disclosed. Hearing Date - Preliminary Hearing on Temporary Custody Date Time of Hearing Date Time of Hearing .M. Hearing Date - Petition .M. Telephone Court Location of Hearing (Number, street, and town) Court Location Publication for: (Name) Name of Person Signing Statutory Mail for: (Name) Signed (Judge, Assistant clerk) (Page 1 of 2) Service on or Before (Date) Return By (Date) Date Signed American LegalNet, Inc. www.FormsWorkFlow.com RETURN OF SERVICE State of Connecticut County of Docket Number Name of Person(s) Served Date of Service SS. Then and there, I duly served the foregoing petition, order and summons on the above-named respondent(s), by either (check one): Fees Copy leaving with (for in hand); or Endorsement leaving at the usual place of abode (for abode) at Service Travel The within and foregoing is a true and attested copy of the original petition, order, and summons. Attest (Signature and title of proper officer) Total State of Connecticut County of Name of Person(s) Served Date of Service SS. Then and there, I duly served the foregoing petition, order and summons on the above-named respondent(s), by either (check one): Fees Copy leaving with (for in hand); or Endorsement leaving at the usual place of abode (for abode) at Service Travel The within and foregoing is a true and attested copy of the original petition, order, and summons. Attest (Signature and title of proper officer) Total State of Connecticut County of Name of Person(s) Served Date of Service SS. Then and there, I duly served the foregoing petition, order and summons on the above-named respondent(s), by either (check one): Fees Copy leaving with (for in hand); or Endorsement leaving at the usual place of abode (for abode) at Service The within and foregoing is a true and attested copy of the original petition, order, and summons. Attest (Signature and title of proper officer) Travel Total For Mail Service State of Connecticut County of United States Post Office at (Town) Date of Service SS. 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): Fees Copy Endorsement restricted delivery, return receipt requested; or first class mail; or certified mail, return receipt requested. Service Travel The within and foregoing is a true and attested copy of the original petition, order, and summons. Attest (Signature and title of proper officer) Total JD-JM-149 Rev. 12-08 (Page 2) (Page 2 of 2) American LegalNet, Inc. www.FormsWorkFlow.com