APPLICATION FOR INVOLUNTARY COMMITMENT/ALCOHOL AND/OR DRUG DEPENDENCY PC-803 REV. 7/12 Page 1 of 2 STATE OF CONNECTICUT RECORDED (CONFIDENTIAL VOLUME): COURT OF PROBATE [Type or print in black ink.] TO: COURT OF PROBATE, DISTRICT NO. IN THE MATTER OF SEX: M F PETITIONER [Name, address, zip code, and telephone number. Please also explain your relationship to the respondent.] Hereinafter referred to as the respondent. PERMANENT ADDRESS OF RESPONDENT JURISDICTION BASED ON RESIDENCE PRESENT ADDRESS OF RESPONDENT [If confined for treatment, give name and address of treatment facility.] DISTRICT WHERE RESPONDENT IS CONFINED FOR TREATMENT DISTRICT WHERE RESPONDENT IS AT THE TIME THE APPLICATION IS FILED [If the respondent is from out of state or residency is unknown.] PERSONS TO WHOM NOTICE SHOULD BE GIVEN: PETITIONER, SPOUSE [If not the petitioner], NEXT OF KIN [If none, so state], PARENT OR LEGAL GUARDIAN [If the respondent is a minor], ADMINISTRATOR OF THE TREATMENT FACILITY [If respondent has been committed for emergency treatment pursuant to C.G.S. §17a-684, as amended], ADMINISTRATOR OF THE TREATMENT FACILITY TO WHICH THE RESPONDENT IS TO BE ADMITTED, and OTHER PERSONS HAVING AN INTEREST IN THE RESPONDENT[Give names, addresses, and zip codes, and relationships to respondent.] C.G.S. §17a-685. THE PETITIONER FURTHER REPRESENTS that said respondent: Is Is not able to request or obtain an attorney. C.G.S. §17a-685(c). Is Is not able to pay for the services of an attorney. [Submit Request Order/Waiver of Fees-Respondent, PC-184A.] The respondent's financial status is unknown to the petitioner. APPLICATION FOR INVOLUNTARY COMMITMENT/ ALCOHOL AND/OR DRUG DEPENDENCY PC-803 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR INVOLUNTARY COMMITMENT/ALCOHOL AND/OR DRUG DEPENDENCY . PC-803 REV. 7/12 Page 2 of 2 STATE OF CONNECTICUT RECORDED (CONFIDENTIAL VOLUME): COURT OF PROBATE [Type or print in black ink .] THE PETITIONER RESPECTFULLY ALLEGES that the named respondent resides in the town shown within this probate district or is now at the present address shown and that said respondent is an alcohol-dependent or drug-dependent person who is dangerous to himself/herself or dangerous to others when intoxicated OR is gravely disabled as defined in C.G.S. §17a-680. At or before the hearing, the petitioner shall file a certificate from a licensed physician who has examined the respondent within two days of the submission of this application. The applicant is a person other than the certifying physician, AND A STATEMENT OF THE FACTS AND INFORMATION UPON WHICH THE APPLICANT BASES THE ALLEGATIONS APPEARS BELOW, ALONG WITH THE NAMES AND ADDRESSES OF PHYSICIANS. [Use Second Sheet, PC-180, if more space is needed.] The petitioner has arranged for treatment in the facility named below, AND A STATEMENT TO THAT EFFECT FROM SAID FACILITY IS ATTACHED HERETO. Name: PROPOSED Address and Zip Code: TREATMENT FACILITY WHEREFORE, PETITIONER REQUESTS that this court find that the respondent is an alcohol or drug-dependent person as set forth herein and that said respondent be ordered committed to a treatment facility for treatment as provided by C.G.S. §17a-685. The representations contained herein are made under the penalties of false statement. DATE: SIGNED ................................................................................................................ Petitioner: ATTORNEY FOR PETITIONER [Name, address, zip code, telephone number, and juris number ] APPLICATION FOR INVOLUNTARY COMMITMENT/ ALCOHOL AND/OR DRUG DEPENDENCY PC-803 American LegalNet, Inc. www.FormsWorkFlow.com