PETITION FOR EMANCIPATION STATE OF CONNECTICUT SUPERIOR COURT JUVENILE MATTERS JD-JM-90 Rev. 7-11 C.G.S. Secs. 46b-150, 150b; PA 11-51, Sec. 19 To: The Superior Court for Juvenile Matters Address of court Telephone number Name of minor child Sex Docket number Age Date of birth Address of child Names Of Parents Or Legal Guardians Name Relationship Petitioner Residence Respondent Minor Father Mother Guardian Minor Father Mother Guardian The Petitioner requests that the court declare that the minor named above is emancipated on the following statutory grounds: (1) The minor is in a valid marriage, whether or not that marriage has been terminated by dissolution. (2) The minor is on active duty with any of the armed forces of the United States of America. (3) The minor willingly lives separate and apart from parents or guardian, with or without the consent of the parents or guardian, and the minor is managing his or her own financial affairs, regardless of the source of any lawful income. (4) For good cause shown, it is in the best interests of the minor, any child of the minor, or the parents or guardian of the minor. State facts and reasons for emancipation (Use additional sheet, if necessary) Signed (Petitioner) Subscribed and sworn to before me: On(Date) Signed (Judge, Assistant Clerk, Notary, Comm. Sup. Court) The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation under the ADA, contact the Court clerk at the number listed above or an ADA contact person listed at www.jud.ct.gov/ADA. Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 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 respondent(s) 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 of abode, or, if so ordered, by publication or mail on or before the date for service shown below and return same to the Court. Hearing date Court location X X Date Time of hearing .M. Number, street and town Publication for: Certified mail for: Service to be made on or before (Date) By order of the Court (Signed - Judge/Clerk of Superior Court) Right to counsel: Date signed If you want an attorney but are unable to pay for one, the Court will make sure that an attorney is provided for you by the Chief Public Defender upon proof of your inability to pay. You should ask for an attorney immediately at the court office where your hearing is to be held. JD-JM-90 (Page 2) Rev. 7-11 Page 2 of 3 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. 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. Copy Endorsement Service Travel Attest (Signature and title of proper officer) 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. Copy Endorsement Service Travel Attest (Signature and title of proper officer) Total STATE OF CONNECTICUT County of Name of person(s) served Date of service SS. Fees Copy 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__________________________________________ Endorsement 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 For Mail Service STATE OF CONNECTICUT County of United States Port 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. Fees Copy Endorsement Service Travel Attest (Signature and title of proper officer) Total JD-JM-90 (Page 3) Rev. 7-11 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com