APPLICATION/APPOINTMENT STATE OF CONNECTICUT RECORDED(CONFIDENTIAL VOLUME): OF TEMPORARY GUARDIAN PC-504 REV. 7/12 Page 1 of 2 COURT OF PROBATE [Type or print in black ink. Complete Confidential Information Sheet for PC-504 on last page.] TO: COURT OF PROBATE, IN THE MATTER OF DISTRICT NO. A MINOR CHILD BORN ON Presently residing at PETITIONER [Name, address, zip code, telephone number, and legal status of petitioner. C.G.S. § 45a-622.] PROPOSED TEMPORARY GUARDIAN [Name, address, zip code, and birth date. ] PERSONS WHO HAVE GUARDIANSHIP RIGHTS WITH RESPECT TO SAID MINOR CHILD [If any is a minor, give date of birth; if incompetent or in military service, so indicate. Give last known address and zip code. C.G.S. § 45a-621.] MOTHER FATHER [Including an unwed father, C.G.S. § 45a-604. If father is unknown, so state.] GUARDIAN(S) OF THE PERSON OF THE MINOR Explain why the parent(s) or guardian(s) is/are unable to care for the minor. [E.g., absence from jurisdiction, illness, etc.] APPLICATION/APPOINTMENT OF TEMPORARY GUARDIAN PC-504 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION/APPOINTMENT OF TEMPORARY GUARDIAN PC-504 REV. 7/12 Page 2 of 2 STATE OF CONNECTICUT RECORDED(CONFIDENTIAL VOLUME): COURT OF PROBATE [Type or print in black ink.] THE PETITIONER FURTHER REPRESENTS that to the best of his or her knowledge and belief: The following respondent(s) is/are under a legal disability: No respondent(s) is under a legal disability. The following respondent(s) is/are in the military service of the United States or Allied Nation (Title 50 Appendix, U.S.C. 520). No respondent(s) is in the military service. There is a no proceeding pending or contemplated in Connecticut or any other state affecting the custody of the minor child. C.G.S. §§ 52-231a and 46b-115 et seq. [Complete and attach form JD-FM-164, Affidavit Concerning Children.] There has been has not been a proceeding in the past in Connecticut or any other state affecting the custody of the minor child. C.G.S. § 52-231a and 46b-115 et seq. is The minor child is not the subject of a pre-existing child support order. 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 minor child has has not resided in Connecticut continuously for the last six months. C.G.S. § 46-115 et seq. WHEREFORE THE PETITIONER REQUESTS that this court appoint a temporary guardian(s) of the person of the minor to commence on 20 the date of the court decree and to terminate one year from the date of the decree OR In no event shall such guardianship exceed the period of one year. The representations contained herein are made under the penalties of false statement. ................................................................................ Petitioner: ..................................................................................... Petitioner: Date: Date: [If petitioner is requesting a waiver of fees, attach PC-184, Request/Order Waiver of Fees - Petitioner.] PROPOSED TEMPORARY GUARDIAN(S) IF APPOINTED, I/WE WILL ACCEPT THE POSITION OF TRUST. Signature ....................................................................................................................................................................... Name [ Type or print.] Address and zip code: Telephone Number(s): Date of Birth: Signature ....................................................................................................................................................................... Name [Type or print.] Address and zip code: Telephone Number(s): APPLICATION/APPOINTMENT OF TEMPORARY GUARDIAN PC-504 Page 2 of 2 Date of Birth: American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL STATE OF CONNECTICUT DO NOT RECORD INFORMATION SHEET FOR PC-504, Application/ COURT OF PROBATE Appointment of Temporary Guardian [Type or Print in Black Ink.] NEW 7/12 _____________________________________________________________________________________ Court of Probate, In the Matter of , a minor child. The social security numbers of the following persons are required in connection with this proceeding: 1) Petitioner: Name: Social Security Number: 2) Proposed Temporary Guardian(s): a. Name: Social Security Number: b. Name: Social Security Number: 3) Persons who have guardianship rights with respect to the minor child: a. Name: Social Security Number: b. Name: Social Security Number: American LegalNet, Inc. www.FormsWorkFlow.com