PETITION: FAMILY WITH SERVICE NEEDS/SCHOOL REFERRAL STATE OF CONNECTICUT SUPERIOR COURT JUVENILE MATTERS www.jud.state.ct.us JD-JM-118A New 6-98 C.G.S. §§ 46b-120, 128, 149 Pr. Bk. Sec's. 29-1, 29-2 ADDRESS OF COURT DOCKET NO. NAME OF CHILD SEX DATE OF BIRTH ADDRESS OF CHILD NAME OF PETITIONER ADDRESS OF PETITIONER RELATIONSHIP TO CHILD PROBATION OFFICER INDIAN RESERVATION, IF ANY PARENT OTHER (Specify): NAME OF MOTHER ADDRESS OF MOTHER NAME OF FATHER ADDRESS OF FATHER NAME OF GUARDIAN, IF ANY ADDRESS OF GUARDIAN INDIAN TRIBE/RESERVATION, IF ANY The Petitioner represents that the above family is a family with service needs, because it includes said child, who is under the age of 16 and was a truant or habitual truant on the following date(s): while in school, has been continually and overtly defiant of school rules and regulations on or about (date(s)) at . Petitioner prays that process issue to bring said child and parent/guardian before the Court. PETITIONER DATED SIGNED (Judge, Asst. Clerk, Notary, Comm. Sup. Crt) ORDER FOR HEARING AND SUMMONS Upon the foregoing petition, it is hereby ORDERED, that said petition be heard and determined at the Court Location shown below on the Hearing Date and time indicated, AND FURTHER ORDERED, that the child and parent/guardian named in this petition be and hereby are summoned to appear before the court on the Hearing Date and at the Court Location shown below by having a proper officer leave a true and attested copy of this order and summons with said respondent(s) or at the usual place or abode, or, if so ordered, by mail on or before the date for service shown below and return same to the court: HEARING DATE COURT LOCATION DATE TIME OF HEARING .M. NO., STREET AND TOWN SERVICE BY (Date) TELEPHONE 1ST CLASS/RESTRICTED MAIL, RETURN RECEIPT: BY ORDER OF THE COURT (Signed - Judge/Clerk) DATE SIGNED NOTICE TO PARENTS AND GUARDIANS An appearance in court as a result of first class mail notice may subject the appearing party to court jurisdiction. Since said child is a minor, he or she must be accompanied by a parent or adult guardian. Failure to appear and obey court orders may result in your being held in contempt and you may be FINED or JAILED or both. See C.G.S. § 46b-121 and § 51-33. RIGHT TO COUNSEL: You have a right to be represented by an attorney and, if you wish an attorney but are unable to pay for one, upon proof that you qualify, the court will provide one for you. Any such request should be made immediately at the court office where your hearing is to be held. 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. (CONTINUED...) American LegalNet, Inc. www.FormsWorkflow.com RETURN OF SERVICE DOCKET NO. STATE OF CONNECTICUT COUNTY OF NAME OF PERSON(S) SERVED. DATE OF SERVICE SS. FEES 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. ATTEST (Signature and title of proper officer) COPY ENDORSEMENT SERVICE TRAVEL TOTAL STATE OF CONNECTICUT COUNTY OF NAME OF PERSON(S) SERVED. DATE OF SERVICE SS. FEES 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. ATTEST (Signature and title of proper officer) COPY ENDORSEMENT SERVICE TRAVEL TOTAL STATE OF CONNECTICUT COUNTY OF NAME OF PERSON(S) SERVED. DATE OF SERVICE SS. FEES 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. ATTEST (Signature and title of proper officer) COPY ENDORSEMENT SERVICE 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): 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) FEES COPY ENDORSEMENT SERVICE TRAVEL TOTAL JD-JM-118A New 6-98 (Back) American LegalNet, Inc. www.FormsWorkflow.com