Revocation Of Order Of Commitment Or Guadianship Custody Or Temporary Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Revocation Of Order Of Commitment Or Guadianship Custody Or Temporary Form. This is a Connecticut form and can be use in Juvenile Statewide.
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STATE OF CONNECTICUT
REVOCATION OF ORDER OF COMMITMENT/GUARDIANSHIP
CUSTODY/TEMPORARY CUSTODY AND SUBSEQUENT
ORDER OF CUSTODY/TEMPORARY CUSTODY
GUARDIANSHIP/PROTECTIVE SUPERVISION
JD-JM-76 Rev. 4-12
C.G.S. § 46b-129(m)
P.B. §§ 26-1(q), 35a-12, 35a-14a, 35a-16
SUPERIOR COURT
JUVENILE MATTERS
www.jud.ct.gov
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 a court clerk
or an ADA contact person listed at www.jud.ct.gov/ADA.
Docket Number
Juvenile Matters At (Address of court)
Name of Minor Child or Youth
Date of Birth
Place of Birth
Name of Mother
Address of Mother
Name of Father
Address of Father
Name of Guardian (If applicable)
Address of Guardian (If applicable)
Order of Custody/Guardianship
The court enters the following orders in the best interest of the child or youth named above at a session of the Superior
Court and in accordance with the statutes that apply to the case:
1. Temporary custody is vested in:
Name (Other than Commissioner of DCF)
Relationship to Child or Youth (if any)
Address
2. The order of
Commitment and/or
Custody
Temporary Custody
to
Guardianship
entered on
with respect to the minor child or youth named above is revoked or modified and the child's or youth's:
Custody
Guardianship
Temporary Custody
Reverts To:
Is Transferred To:
Is vacated
Name (Other than Commissioner of DCF)
Relationship to Child or Youth (If any)
Address
3.
Protective Supervision is ordered, beginning
until
The child or youth is to reside with the custodian and/or guardian named above subject to the
services and steps set out in the Specific Steps.
Dated At (Town)
On (Date)
By (Type name of Judge)
Signed (Judge/Clerk)
Distribution:
Original - File
Copy 1 - Parent or Guardian
Copy 2 - Commissioner of D.C.F.
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