APPLICATION/ EMANCIPATION OF MINOR PC-905 REV. 7/12 STATE OF CONNECTICUT RECORDED(CONFIDENTIAL VOLUME): COURT OF PROBATE [Type or print in black ink.] TO: COURT OF PROBATE, DISTRICT NO. NAME,ADDRESS, and TELEPHONE NUMBER OF MINOR DATE OF BIRTH SEX AGE NAMES OF PARENTS OR LEGAL GUARDIANS OR OTHER INTERESTED PERSONS Relationship to Minor Name PETITIONER: Minor Parent/Guardian Residence[Street, Town, and Zip Code] RESPONDENT Minor Tel. Number Parent/Guardian Jurisdiction is based on the residence of either the minor or his parents or guardian in this probate district. WHEREFORE, the petitioner requests that the court declare that the above-named minor be emancipated on the following statutory grounds: (1) The minor has entered into a valid marriage whether or not that marriage has been terminated by dissolution; or (2) The minor is on active duty with any of the armed forces of the United States of America; or (3) The minor willingly lives separate and apart from his or her 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; or (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/REASONS FOR EMANCIPATION [Use Second Sheet, PC-180, if more space is needed.] There is is not a current safety or service agreement between the Department of Children and Families and the parent/guardian of the minor child. There is is not a current protective order or restraining order involving any party. If so, please attach. The representations contained herein are made under the penalties of false statement. Date: APPLICATION/EMANCIPATION OF MINOR PC-905 ......................................................................... Petitioner: American LegalNet, Inc. www.FormsWorkFlow.com