CONNECTICUT PROBATE COURTS Petition/Appointment of Temporary Guardian PC - 504 REV. 10/18 CONFIDENTIAL Petition/Appointment of Temporary Guardian PC-5RECEIVED : Instructions: 1) Any parent or court-appointed guardian (other than a temporary guardian) of the person of a minor may use this form to petition for the appointment of a temporary guardian of the minor. 2)The petition must be filed in the probate district in which the minor child resides, is domiciled or islocated at the time of filing the petition. 3) A birth certificate (long form) and JD-FM-164, Affidavit Concerning Children, must be filed with the 4) A temporaryterminated sooner by the petitioner. 5)For more information, see C.G.S. section 45a-622. 6) Type or print the form in ink. Use an additional sheet, or PC - Probate Court Name District Number In the Matter of Hereinafter referred to as the minor child Minor Child222s Date of Birth Address where minor child resides Address where minor child is domiciled (if different) Petitioner (Name, address and telephone number) Proposed Temporary Guardian (Name, address, telephone number and birth date) Parent Court - appointed Guardian Persons who have Guardianship R ights with Respect to the Minor Child (For each person, list name, address, telephone number, including the date of birth for any person who is under the age of 18, any person in the military service or any person under conservatorship or legal disability.) Mother /Parent Father/Parent (If father is unknown, so state.) Guardian(s) of the Person of the Minor Child American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Petition/Appointment of Temporary Guardian PC - 504 REV. 10/18 CONFIDENTIAL Petition/Appointment of Temporary Guardian State the reason(s) why the parent or guardian is unable to care for the minor child. The petitioner further represents that to the best of his or her knowledge and belief: The minor child has resided has not resided in Connecticut continuously for the last six months. There is a proceeding is not a proceeding pending or contemplated in Connecticut or any other state affecting the custody of the minor child. There has been a proceeding has not been a proceeding in the past in Connecticut or any other state affecting the custody of the minor child. 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 is is not the subject of a pre-existing child support order. WHEREFORE the petitioner requests that the court appoint a temporary guardian(s) of the person of the minor child to begin on the date of the court decree and to terminate one year from the date of the decree OR to terminate on . In no event shall the guardianship exceed the period of one year. The representations made in this petition are made under penalty of false statement. Signature of Petitioner Type or Print Name Date Signature of Petitioner Type or Print Name Date PROPOSED TEMPORARY GUARDIAN If appointed, I will accept the position of trust as temporary guardian. Signature Type or Print Name Date Address Telephone number Signature Type or Print Name Date Address Telephone number PC-504 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL INFORMATION CONNECTICUT PROBATE COURTS Petition/Appointment of Tem porary Guardian PC - 504CI REV. 10/1 7 FOR COURT USE ONLY Confidential Information/Petition/Appointment of Te mporary Guardian PC - 504CI RECEIVED : Probate Court Name District Number In the Matter of , a minor child The social security numbers of the following persons are required in connection with this proceeding. 1)Mother/Parent:Name Social Security Number 2)Father/Parent:Name Social Security Number 3)Court-appointed Guardian of the Person:Name Social Security Number 4)Proposed temporary guardian:Name Social Security Number American LegalNet, Inc. www.FormsWorkFlow.com