ORDER OF TEMPORARY CUSTODY - FWSN STATE OF CONNECTICUT SUPERIOR COURT JUVENILE MATTERS www.jud.ct.gov JD-JM-123 Rev. 8-11 C.G.S. 46b-149(f), PA 11-51, Sec. 19, PA 11-240, Sec. 2 Address of Court Docket number Telephone number Name and address of child Date of birth Name and address of mother Name and address of father Name of guardian (if any) and address Name and address of putative father (if any) If parent(s) is/are minor(s), name(s) and address(es) of grandparent(s) or guardian(s) Upon the petition and the verified affirmation of facts, the court finds: (A) A strong probability that the child may do something that is injurious to himself/herself prior to court disposition; (B) a strong probability that the child will run away prior to the hearing; or (C) a need to hold the child for another jurisdiction, and further that the conditions or the circumstances surrounding the care of the child require that custody be immediately assumed to safeguard the welfare of the child and that continuation in the home is contrary to the welfare of the child, AND Reasonable efforts to prevent or eliminate the need for removal of the child were made by the state; Reasonable efforts to prevent or eliminate the need for removal of the child from the home were not possible; or Reasonable efforts were not made. It is hereby ordered that: the child be given into the temporary custody of pending a hearing as set forth below on the confirmation of this order. And it is further ordered that the child/mother/father/guardian named above be and hereby 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. Hearing Date - Temporary Custody T Date Time of hearing Hearing Date - Petition T Date Time of hearing Publication for: Name of Judge .M. .M. Certified mail for: Service to be made on or before (Date) Return date Date signed Signed (Judge) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com RIGHT TO COUNSEL AND TO REMAIN SILENT: If you want an attorney to represent you but are unable to pay for one, upon proof of your inability to pay, the court will ensure that an attorney is provided for you by the Chief Public Defender. A request for an attorney should be made immediately at the court office where your hearing is to be held. Any child shall have the right to remain silent at any stage of the proceedings. A parent or guardian may elect or refuse to testify for or against a child who is the subject of a family with service needs proceeding. If a petition is filed alleging the child is neglected, uncared for or abused dependent, the parent or guardian has the right to remain silent at any stage of the proceedings and cannot be forced to testify if the testimony might tend to incriminate in any criminal proceeding or to establish the validity of the facts alleged in the petition. ADA Notice 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 the court clerk at the number listed above or an ADA contact person at www.jud.ct.gov/ADA. Return Of Service Docket number 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) Service at The within and foregoing is a true and attested copy of the original petition, order, and summons. Travel 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) Service at The within and foregoing is a true and attested copy of the original petition, order, and summons. Travel Attest (Signature and title of proper officer) 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 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. Total Attest (Signature and title of proper officer) JD-JM-123 Rev. 8-11 (Page 2) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com