APPLICATION/COMMITMENT OF MENTALLY ILL CHILD PC-800 REV. 10/01 STATE OF CONNECTICUT RECORDED (CONFIDENTIAL VOLUME): COURT OF PROBATE [Type or print in black ink.] TO: COURT OF PROBATE, DISTRICT OF DISTRICT NO. IN THE MATTER OF DATE OF BIRTH OF CHILD HEREINAFTER REFERRED TO AS THE CHILD, A PROCEEDING FOR COMMITMENT PETITIONER [Name, address, and zip code] PRESENT ADDRESS OF CHILD [If institutionalized, give name and address of institution.] JURISDICTION BASED ON RESIDENCE DISTRICT WHERE CHILD IS HOSPITALIZED DISTRICT WHERE CHILD IS AT THE TIME THE APPLICATION IS FILED [If the child is from out of state or residency is unknown.] PROPOSED HOSPITAL, per C.G.S. §17a-77. [Name, address,and zip code] ATTORNEY APPOINTED FOR THE CHILD BY THE SUPERIOR COURT per C.G.S. §46b-129, if applicable. C.G.S. §17a-76. [Name, address, zip code, and telephone number.] PERSONS TO WHOM NOTICE SHOULD BE GIVEN: PARENTS, CLOSEST RELATIVES [If none, so state] and INTERESTED PARTIES as defined in Probate Practice Book, Rule 3.1.02 [Give names, addresses, zip codes, and relationships to child. If attorney for child or parents, please list juris number.] Additional data [on Second Sheet, PC-180] if any, is made a part hereof. THE PETITIONER REPRESENTS that said CHILD: Is now living at the present address written above. Is Is not a patient in a hospital. C.G.S. §17a-76. Suffers from a mental disorder and is in need of treatment. C.G.S. §17a-76. WHEREFORE, THE PETITIONER REQUESTS that this Court make an order for the above child's confinement to a hospital for mental illness of children. The representations contained herein are made under the penalties of false statement. Date: APPLICATION/COMMITMENT OF MENTALLY ILL CHILD PC-800 ...................................................................................... Petitioner: American LegalNet, Inc. www.FormsWorkFlow.com