APPLICATION TEMPORARY CUSTODY Page 1 PC-502 REV. 10/04 STATE OF CONNECTICUT RECORDED(CONFIDENTIAL VOLUME): COURT OF PROBATE [Type or print in black ink. File in duplicate.] TO: COURT OF PROBATE, DISTRICT OF DISTRICT NO. IN THE MATTER OF [Name, address where residing, and zip code.] MINOR CHILD'S BIRTH DATE The minor child is the subject of a pre-existing child support order. Hereinafter referred to as the minor child. PETITIONER [Name, address, zip code, telephone number, and legal status of petitioner (e. g. adult relative, counsel for minor). If adult relative, also give date of birth and social security number. If counsel for minor, also list juris number.] PARENT(S)/GUARDIAN(S) [Name(s), address(es), zip code(s), and telephone number(s). Indicate parent/guardian to be removed/ terminated. If parent, state date of birth and social security number.] MINOR CHILD IS PRESENTLY IN THE CUSTODY OF [Name, address, zip code, and telephone number. Give relationship to minor child.] THE PETITIONER REPRESENTS that: An application is pending in this court for the removal of one or both parents as guardians or for the removal of the guardian of said minor child; OR An application is pending in this court for the termination of parental rights with respect to said minor child; OR The petitioner has reasonable grounds to believe that said minor child has no guardian of his or her person. The parent(s) or other guardian(s) consent to the minor child's temporary removal. [No further allegation is necessary against a consenting parent/guardian. ] THE PETITIONER FURTHER REPRESENTS that the parent or other guardian has performed acts of omission or commission as set forth in C.G.S.§45a-610: The minor child has been abandoned by the parent in the sense that the parent has failed to maintain a reasonable degree of interest, concern, or responsibility for the child's welfare. C.G.S. §45a-610(2). The minor child has been denied the care, guidance, or control necessary for physical, educational, moral, or emotional well-being as defined by law. C.G.S. §45a-610(3). The minor child has had physical injuries inflicted upon him or her by a person responsible for such child's health, welfare, or care, or by a person given access to such child by such responsible person, other than by accidental means, or has injuries which are at variance with the history given of them or is in a condition which is the result of maltreatment such as, but not limited to, malnutrition, sexual molestation, deprivation of necessities, emotional maltreatment, or cruel punishment. C.G.S. §45a-610(4). AND BECAUSE OF SUCH ACTS, THE CHILD IS SUFFERING FROM SERIOUS PHYSICAL ILLNESS, SERIOUS PHYSICAL INJURY, OR THE IMMEDIATE THREAT THEREOF, OR IS IN IMMEDIATE PHYSICAL DANGER. THE PETITIONER ALLEGES the following specific actions, omissions, etc., which cause the child to suffer serious physical illness or serious physical injury, or the immediate threat thereof, or place him or her in immediate physical danger. Included are dates, times, and places. [To give further details, use Second Sheet, PC-180.] Continued APPLICATION/TEMPORARY CUSTODY PC-502 Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com APPLICATION TEMPORARY CUSTODY Page 2 PC-502 REV. 8/02 RECORDED(CONFIDENTIAL VOLUME): STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink. File in duplicate.] THE PETITIONER FURTHER REPRESENTS that 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 proceeding is pending or contemplated, give full details.] [To give further details, use Second Sheet, PC-180.] THE PETITIONER FURTHER REPRESENTS that it is in the best interest of said minor child that temporary custody of said minor child be granted to a proper person as provided in C.G.S. §45a-610, pending the determination of the aforesaid matter. WHEREFORE THE PETITIONER REQUESTS that an order for temporary custody for said minor child be granted to: [ Give relationship to minor child, if any.] The representations contained herein are made under the penalties of false statement. Date: ........................................................................................ Petitioner: PROPOSED TEMPORARY CUSTODIAN IF APPOINTED, I WILL ACCEPT SAID POSITION OF TRUST. Signature .............................................................................................................................................. Name [Type or print. Include maiden name, if applicable.] Address and zip code: Telephone Number: Date of birth: CONSENT TO TEMPORARY CUSTODY I do consent under penalty of false statement to an order of temporary custody of said minor child. [Any consent for an incompetent or minor parent must be approved by a guardian ad litem. C.G.S. §45a-621. To waive personal service, form PC-633, Waiver of Personal Service, Parental Rights Matters, must be filed.] Date: ........................................................................... Parent's/Guardian's Signature Type Name: Date: ........................................................................... Parent's/Guardian's Signature Type Name: Date: ........................................................................... Parent's/Guardian's Signature Type Name: APPLICATION/TEMPORARY CUSTODY PC-502 Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com