RECORDED (CONFIDENTIAL VOLUME): APPLICATION RE: PLACEMENT FOR OUT-OF-STATE ADOPTION PC-608 NEW 10/2011 STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink.] TO: COURT OF PROBATE, IN THE INTEREST OF: [Name of minor] DISTRICT NO. DATE OF BIRTH PETITIONER [Name, address, zip code and telephone number] POSITION OF TRUST INTERESTED PARTIES: [Attorney for minor child, guardian(s), adopting parent(s), statutory parent and other interested parties, if any] The petitioner represents that the _________________________________Probate Court terminated the parental rights in regard to the above-named minor by decree dated ______________________ and appointed: The Department of Children and Families as statutory parent of the minor. [Name of agency]______________________________________________ as statutory parent of the minor. [Name of guardian]______________________________________________ as guardian of the minor. The petitioner further represents that: There is a proposed placement for an out-of-state adoption of said minor. The State of Connecticut has received notice in writing from [Name of receiving state] ____________________, in accordance with subsection (d) of Article III of C.G.S. § 17a-175, indicating that the proposed placement does not appear contrary to the interests of the child. There is is not a home study completed by [Name of receiving state] ____________________________. WHEREFORE, THE PETITIONER REQUESTS that this court approve the proposed placement of the minor for an outof-state adoption in accordance with C.G.S. § 45a-717(j), as amended. The representations contained herein are made under the penalties of false statement. Date: _____________________________ _________________________________ Petitioner APPLICATION RE: PLACEMENT FOR OUT-OF-STATE ADOPTION PC-608 NEW 10/2011 American LegalNet, Inc. www.FormsWorkFlow.com