PETITION: NEGLECTED, UNCARED-FOR, ABUSED CHILD/YOUTH JD-JM-98 Rev. 12-15 C.G.S. §§ 46b-120, 121, 129; PA 14-186 § 5; P.B. §§ 32a-1(g), 33a-1, 33a-2 STATE OF CONNECTICUT SUPERIOR COURT JUVENILE MATTERS www jud.ct.gov Docket number Telephone number Place and date of birth Fax number Sex TO: The Superior Court For Juvenile Matters Address of court Name and address of child/youth Name and address of petitioner Relationship to Child or Youth Commissioner D.C.F. Probation Officer Other (Specify) Date of birth Date of birth Date of birth Date of birth Indian tribe/reservation Indian tribe/reservation Indian tribe/reservation Indian tribe/reservation Respondents 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): The Petitioner Represents that the Child or Youth Is: Neglected for reasons other than being impoverished in that the child or youth has been abandoned; the child or youth is being denied proper care and attention, physically, educationally, emotionally or morally; or the child or youth is being permitted to live under conditions, circumstances or associations injurious to well-being. Uncared for in that the child or youth is homeless; or the child's or youth's home cannot provide the specialized care which the physical, emotional or mental condition of the child or youth requires; or the child or youth has been identified as a victim of trafficking Abused in that the child or youth has physical injury or injuries inflicted by other than accidental means; or the child has injuries that are at variance with the history given of them; or the child is in a condition that is the result of maltreatment including but not limited to malnutrition, sexual molestation or exploitation, deprivation of necessities, emotional maltreatment or cruel punishment. State jurisdictional facts (Use additional sheet if necessary) The Petitioner requests that process issue to bring the parents, or legal custodian of the child or youth before the court to be dealt with according to law. Signed (Petitioner) Subscribed and sworn to before me on (Date) Signed (Judge, Assistant Clerk, Notary, Comm. Superior Court) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Order For Hearing And Summons Docket number Upon the foregoing petition, it is ordered, that the petition be heard and determined at the Court Location shown below on the Hearing Date and time indicated, and further ordered, that the petitioner shall serve a copy of the foregoing petition on each parent/guardian named in this petition and they 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 the 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. Date Time of hearing Hearing date Court location u u Number, street and town Publication for: Service to be made on or before (Date) By order of the Court (Signed - Judge/Clerk of Superior Court) Date signed Certified mail for: .M. 1. Failure to Appear: If you do not come to court, the court may find that your child is neglected, uncared-for or abused. 2. Right to Counsel: You have the right to be represented by an attorney and if you want an attorney but cannot pay for one, and if you give proof that you cannot pay, the court will make sure that an attorney is provided for you by the Chief Public Defender. Your request for an attorney should be made immediately by filling out the JD-JM-114 Application for Appointment of Counsel/Waiver of Fees form. Submit the application form in person, by mail or fax at the court location where your hearing is going to be. 3. Right to Remain Silent. You have the right to refuse to make statements; any statements you make may be introduced in evidence and used against you. ADA Notice 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. JD-JM-98 Rev. 12-15 Page 2 of 3 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 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 SS. Name of person(s) served Date of service 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 SS. Name of person(s) served Date of service 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 SS. For Mail Service United States Port Office at (Town) 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, a