APPLICATION -- CONSENT TERMINATION STATE OF CONNECTICUT OF PARENTAL RIGHTS WITH STEPPPARENT, CO-PARENT OR RELATIVE ADOPTION COURT OF PROBATE PC-601 REV. 10/11 Page 1 of 3 [Type or print in black ink. File in duplicate.] RECORDED (CONFIDENTIAL VOLUME): [Attach certified copy of birth certificate; Adoption Data Sheet, PC-680; Agreement of Adoption, PC-681; and Affidavit of Consent to Termination of Parental Rights, JD-JM-60.] [If any information is unknown, so state in each box.] TO: COURT OF PROBATE, DISTRICT OF IN THE INTEREST OF [Name, present address, zip code, sex] DISTRICT NO. PLACE OF BIRTH OF MINOR CHILD DATE OF BIRTH OF MINOR CHILD a person under 18 years of age, hereinafter referred to as the minor child. The minor child is presently or was formerly the recipient of state Party whose parental rights are to be terminated is assistance. under a court order to pay child support. Jurisdiction based on: Petitioner or minor child resides in the probate district. Minor child is under the guardianship of a duly-licensed child care or child-placing agency, which has an office in the probate district. PETITIONER [Name, address, zip code, telephone number, the nature of the relationship to minor child and legal status of petitioner. C.G.S. §45a-715.] PARENT(S) OF MINOR CHILD [Name(s), address(es), social security number(s), and tribe and reservation if American Indian as defined in P.L. 95-608] MOTHER: MOTHER'S DATE OF BIRTH: FATHER: FATHER'S DATE OF BIRTH: ADOPTING PARENT(S) [Name(s), address, zip code, and telephone number] IF PARENT(S) TO BE TERMINATED IS A MINOR, LIST THE PARENT OR GUARDIAN OF THE MINOR PARENT(S). [Name(s), address(es), zip code(s), telephone number(s), and relationship] GUARDIAN OF PERSON OF MINOR CHILD, if other than parent and GUARDIAN AD LITEM APPOINTED IN PRIOR PROCEEDING(S), if any. [Name(s), address(es), zip code(s), and telephone number(s)] APPLICATION -- CONSENT TERMINATION OF PARENTAL RIGHTS WITH STEPPARENT, CO-PARENT OR RELATIVE ADOPTION American LegalNet, Inc. Continued www.FormsWorkFlow.com PC-601 Page 1 of 3 APPLICATION -- CONSENT TERMINATION STATE OF CONNECTICUT OF PARENTAL RIGHTS WITH STEPPPARENT, COURT OF PROBATE CO-PARENT OR RELATIVE ADOPTION PC-601 REV. 10/11 Page 2 of 3 RECORDED(CONFIDENTIAL VOLUME): TRIBE AND RESERVATION of minor child, if an American Indian as defined in P.L. 95-608. [Name, address, and zip code] AGENCY THAT PLACED THE CHILD IN CURRENT PLACEMENT [Name, address, and zip code] THE PETITIONER REPRESENTS that: The adopting parent(s) resides in this probate district. The Adoption Data Sheet, PC-680, and attached exhibits submitted with this application are a part hereof, and the factual information in such documents and the data herein provided are true and complete to the best knowledge and belief of the petitioner. There is a no proceeding pending or contemplated in another court affecting the custody of said minor child to the best knowledge and belief of the petitioner. C.G.S. §52-231a.[If such a proceeding is pending or contemplated, complete and attach form JD-FM-164, Affidavit Concerning Children.] THE PETITIONER FURTHER REPRESENTS that: father mother of said minor child consents to the termination of any parental rights with respect to said minor child. [Any consent to termination of parental rights must be accompanied by an Affidavit of Consent to Termination of Parental Rights, JD-JM-60. C.G.S. §45a-715(d). Attach statement made under oath of facts relating to consent termination.] The sole parent of said minor child has entered into an Adoption Agreement for the adoption of said minor child with his or her spouse, in no way relinquishing any parental rights to said minor child. The sole parent of said minor child has entered into an Adoption Agreement for the adoption of said minor child with a person who shares parental responsibility for the child with such parent, in no way relinquishing any parental rights to said minor child. The parent(s) of said minor child have entered into an Adoption Agreement for the adoption of said minor child with the adopting parent(s), one of whom is a blood relative descended from a common ancestor not more than three (3) generations removed from said minor child. C.G.S. §45a-724(a). WHEREFORE, THE PETITIONER REQUESTS that this Court: Approve the Adoption Agreement submitted herewith between the parent(s) of said minor child and the adopting parent(s) and PETITIONS the Court to: terminate the parental rights of change the name of said minor child to The representations contained herein are made under the penalties of false statement. ....................................................................................................... Guardian Ad Litem: ..................................................................................................... Petitioner: Date: Date: [Any signature by an incompetent or minor petitioner must be approved by a guardian ad litem. C.G.S. §45a-715.] Continued APPLICATION -- CONSENT TERMINATION OF PARENTAL RIGHTS WITH STEPPARENT, CO-PARENT OR RELATIVE ADOPTION American LegalNet, Inc. www.FormsWorkFlow.com PC-601 Page 2 of 3 APPLICATION -- CONSENT TERMINATION STATE OF CONNECTICUT RECORDED (CONFIDENTIAL OF PARENTAL RIGHTS WITH STEPPPARENT, COURT OF PROBATE CO-PARENT, OR RELATIVE ADOPTION PC-601 REV. 10/11 Page 3 of 3 [For legal effects of a Termination of Parental Rights Decree, see below.] VOLUME): CONSENT TO TERMINATION I do consent to termination of my parental rights. [Any consent for an incompetent or minor parent must be signed by a guardian ad litem. C.G.S. §45a-708. Any consent to termination of parental rights must be accompanied by Affidavit of Consent to Termination of Parental Rights, JD-JM-60. C.G.S. §45a-715. To waive personal service, form PC-633, Waiver of Personal Service Parental Rights Matters, must be filed.] DATE DULY ACKNOWLEDGED BEFORE ME ........................................................................................... Father: ........................................................................................... Mother: ........................................................................................... Guardian Ad Litem: ..................................................................................... Judge, Ass't Clerk, Notary Public, Comm. Sup.Ct. ..................................................................................... Judge, Ass't Clerk, Notary Public, Comm. Sup.Ct. ................................................................................... Judge, Ass't Clerk, Notary Public, Comm. Sup.Ct. JOINDER AND CONSENT OF MINOR CHILD I, the minor child, having attained the age of twelve years, do join in this application for termination of parental rights and consent to the granting of this adoption. C.G.S. §45a-724. ........................................................................................ Minor Child: LEGAL EFFECTS OF A TERMINATION OF PARENTAL RIGHTS DECREE Termination of parental rights means "the complete severance by court order of the legal relationship, with all its rights and responsibilities, upon the effective date of the termination, between the child and his parent or parents so that the child is free for adoption except it shall not affect the right of inheritance of the child or the religious affiliation of the child." C.G.S. §45a-707(8). (Inheritance rights cease upon adoption.) No action taken with respect to the termination of parental rights of one parent affects the parental rights of the other parent. Upon a decree of termination of parental rights, the parent will NO LONGER have the following rights and responsibilities with respect to the minor child who is the subject of the decree: the legal right to custody, guardianship, or control of the child. The parent will have no legal right to care for the child or make any decisions on behalf of the child. the legal right to the child's birth certificate. the legal right to any state and federal benefits the parent may have been receiving for the child. the legal responsibility to support the child and to pay for the child's maintenance, medical, and other expenses, but the parent MAY be responsible for support of the child until the effective date of the termination. the legal responsibility to care for the child or make any decisions on his or her behalf. APPLICATION -- CONSENT TERMINATION OF PARENTAL RIGHTS WITH STEPPARENT, CO-PARENT, OR RELATIVE ADOPTION American LegalNet, Inc. www.FormsWorkFlow.com PC-601 Page 3 of 3