APPLICATION/ADOPTION PC-603 REV. 10/09 RECORDED(CONFIDENTIAL VOLUME): STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink. File in duplicate.] [Attach Adoption Data Sheet, PC-680 and Agreement of Adoption, PC-681.] TO: COURT OF PROBATE, DISTRICT OF DISTRICT NO. IN THE MATTER OF DATE OF BIRTH OF MINOR CHILD Hereinafter referred to as the minor child. PETITIONER/PERSON GIVING MINOR CHILD IN ADOPTION[Name, address, zip code, and telephone number] C.G.S. §45a-724(a) Statutory Parent Sole Parent of Minor Child Guardian of the Person ADOPTING PARENT(S)[Name, address, zip code, and telephone number] THE PETITIONER REPRESENTS that: The adopting parent(s) reside in this probate district or the main or a local office of the statutory parent, if any, is located in this district. The Adoption Data Sheet, PC-680, and attached exhibits submitted with this application are a part hereof, and the factual information in such documents and the data herein provided are true and complete to the best knowledge and belief of the petitioner. The minor child is free for adoption. C.G.S. §45a-725. There is a no proceeding pending or contemplated in another court affecting the custody of said minor child to the best knowledge and belief of the petitioner. C.G.S. §45a-727. [If such a proceeding is pending or contemplated, complete and attach form JD-FM-164, Affidavit Concerning Children.] The statutory parent for said minor child has entered into an Adoption Agreement for the adoption of said minor child with the adopting parent(s) named above. The sole parent of said minor child has entered into an Adoption Agreement for the adoption of said minor child with his or her spouse. C.G.S. §45a-724(a)(2). The sole parent of said minor child has entered into an Adoption Agreement for the adoption of said minor child with a person who shares parental responsibility for the child with such parent. C.G.S. §45a-724 (a)(3) The guardian of the person of said minor child has entered into an adoption agreement for the adoption of said minor child with the adopting parent(s) named above, one of whom is a blood relative descended from a common ancestor not more than three generations removed from said minor child. C.G.S. §45a-724(a)(4). WHEREFORE, THE PETITIONER REQUESTS that this Court: Approve the Adoption Agreement submitted herewith between the statutory parent, the sole parent,or the guardian of the person of the minor child, and the adopting parent(s). Change the name of said minor child to The representations contained herein are made under the penalties of false statement. Date: ........................................................................ Petitioner: CONSENT OF MINOR CHILD I, the minor child, having attained the age of twelve, do consent to this application. C.G.S. §45a-724. ............................................................................................... Minor Child: APPLICATION/ADOPTION PC-603 American LegalNet, Inc. www.FormsWorkFlow.com