APPLICATION/TERMINATION OF PARENTAL RIGHTS PC-600 REV. 7/12 Page 1 STATE OF CONNECTICUT COURT OF PROBATE RECORDED (CONFIDENTIAL VOLUME): [Type or print in black ink. Indicate if any information is unknown. Attach: 1) certified copy of birth certificate and 2) statement of facts under oath relating to grounds for termination. (See page 2.) Complete Confidential Information Sheet for PC-600 on last page. File this form in duplicate.] TO: COURT OF PROBATE, 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. TRIBE AND RESERVATION of minor child, if an Indian child as defined by P.L. 95-608, 25 U.S.C. 1901, et seq. [Name and address] The minor child is presently or was formerly the recipient of state assistance. Party whose parental rights are to be terminated is 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), and Indian tribe and reservation, if a member as defined by P.L. 95-608, 25 U.S.C.1901, et. seq.] MOTHER: MOTHER'S DATE OF BIRTH FATHER: [Include putative father named by the mother.] FATHER'S DATE OF BIRTH The petitioner represents that the whereabouts of the parent(s) or putative father are unknown. [If this box is checked, complete affidavit section at bottom of Page 3.] IF PARENT(S) TO BE TERMINATED IS A MINOR, LIST THE PARENT OR GUARDIAN OF THE MINOR PARENT. [Name(s), address(es), zip code(s), telephone number(s), and relationship] APPLICATION/TERMINATION OF PARENTAL RIGHTS PC-600 Page 1 of 5 Continued American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION/ TERMINATION OF PARENTAL RIGHTS PC-600 REV. 7/12 Page 2 STATE OF CONNECTICUT RECORDED (CONFIDENTIAL VOLUME): COURT OF PROBATE [For the legal effects of a Termination of Parental Rights Decree, see page 5.] 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)] AGENCY THAT PLACED THE CHILD IN CURRENT PLACEMENT. [Name, address, and zip code] THE PETITIONER REPRESENTS that the MINOR CHILD presently resides in the town named above, was born on the date written above, and the persons who may have parental rights are as stated above, AND THAT the parental rights of the person(s) indicated below should be terminated for the following reasons, as provided by statute. Attached hereto and made a part hereof is a statement of facts made under oath relating to each ground for termination. C.G.S. § 45a-717. See notice below. NOTICE -- IN ORDER TO GRANT THE PETITION, THE COURT MUST MAKE FINDINGS IN REGARD TO: (1) The timeliness, nature, and extent of services offered, provided, and made available to the parent and the child by an agency to facilitate the reunion of the child with the parent. (2) The terms of any applicable court order entered into and agreed upon by any individual or agency and the parent and the extent to which all parties have fulfilled their obligations under such order. (3) The feelings and emotional ties of the child with respect to his parents, any guardian of his person, and any person who has exercised physical care, custody, or control of the child for at least one year and with whom the child has developed significant emotional ties. (4) The age of the child. (5) The efforts the parent has made to adjust his circumstances, conduct, or conditions to make it in the best interest of the child to return him to his home in the foreseeable future, including, but not limited to, (A) the extent to which the parent has maintained contact with the child as part of an effort to reunite the child with the parent, provided the court may give weight to incidental visitations, communications, or contributions and (B) the maintenance of regular contact or communication with the guardian or other custodian of the child. (6) The extent to which a parent has been prevented from maintaining a meaningful relationship with the child by the unreasonable act or conduct of the other parent of the child, or the unreasonable act of any other person, or by the economic circumstances of the parent. THE PETITIONER REPRESENTS that the termination of the parental rights of is in the best interests of the child, AND THAT consent(s) to termination of their parental rights with respect to the minor child. [No further allegation is necessary against a consenting parent. However, an Affidavit of Consent to Termination of Parental Rights, JD-JM-60, and a statement of facts related to this ground for termination must accompany this application.] OR Continued APPLICATION/TERMINATION OF PARENTAL RIGHTS PC-600 Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION/ STATE OF CONNECTICUT RECORDED (CONFIDENTIAL TERMINATION OF COURT OF PROBATE PARENTAL RIGHTS PC-600 REV. 7/12 Page 3 [For legal effects of a Termination of Parental Rights Decree, see page 5. ] VOLUME): The child has been abandoned by in the sense that the parent has failed to maintain a reasonable degree of interest, concern, or responsibility as to the welfare of the child. OR The child has been denied the care, guidance, or control necessary for the child's physical, educational, moral, or emotional well-being, by reason of acts of parental commission or omission by There has been a nonaccidental or inadequately explained serious physical injury to the child. There has been sexual molestation and exploitation, severe physical abuse, or a pattern of abuse. OR There is no ongoing parent/child relationship as defined in C.G.S. § 45a-717(g), and to allow further time for the establishment or reestablishment of the parent/child relationship would be detrimental to the best interests of the child. OR The child is found to be neglected or uncared for AND has been in the custody of the Commissioner of the Department of Children and Families for at least fifteen months, AND the parent has been provided specific steps to take to facilitate the return of the child to the parent pursuant to C.G.S. § 46b-129, as amended, AND the parent has failed to achieve such degree of personal rehabilitation as would encourage the belief that, within a reasonable time and considering the age and needs of the child, such parent could assume a responsible position in the life of the child. OR The child has been found in a prior proceeding by the Probate Court for the District of or the Superior Court for the Judicial District of to have been neglected or uncared for, AND the parent has failed to achieve such degree of personal rehabilitation as would encourage the belief that, within a reasonable time and considering the age and needs of the child, such parent could assume a responsible position in the life of the child. OR The child is under seven years of age AND is neglected or uncared for, AND the parent of the child has failed, is unable, or is unwilling to achieve such degree of personal rehabilitation as would encourage the belief that, within a reasonable amount of time, considering the age and needs of the child, such parent could assume a responsible position in the life of the child, AND such parent's parental rights of another child were previously terminated pursuant to a petition filed by the Commissioner of Children and Families. OR The parent has killed through deliberate, nonaccidental act, another child of the parent OR has requested, commanded, importuned, attempted, conspired, or solicited such killing OR has committed an assault through deliberate and nonaccidental act that has resulted in serious bodily injury to another child of the parent. OR The parent was convicted as an adult or as a delinquent by a court of competent jurisdiction of sexual assault resulting in the conception of a child EXCEPT for a violation of C.G.S. § 53a-71 or C.G.S. § 53a-73a. IF THE WHEREABOUTS OF THE PARENT(S) OR PUTATIVE FATHER ARE UNKNOWN, the petitioner makes affidavit that a diligent search has been made for the missing parent(s) or putative father as set forth below: [If more space is needed, use Second Sheet, PC-180.] APPLICATION/TERMINATION OF PARENTAL RIGHTS PC-600 Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com RECORDED(CONFIDENTIAL VOLUME): APPLICATION/ STATE OF CONNECTICUT TERMINATION OF COURT OF PROBATE PARENTAL RIGHTS PC-600 REV. 7/12 Page 4 [For the legal effects of a Termination of Parental Rights Decree, see Page 5.] 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. The minor child is 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. THE PETITIONER FURTHER REPRESENTS that all of the information contained herein is true to the best of his or her knowledge and belief. WHEREFORE, THE PETITIONER REQUESTS that this court terminate the parental rights of ,and PETITIONS the court to: appoint a statutory parent for the minor child, adoption being contemplated. [A copy of any consent to adoption previously executed by a parent to an authorized agency shall accompany this application.] appoint a guardian(s) of the person of the minor child. affirm that the remaining parent shall be the sole parent and natural guardian of the minor child. Proposed statutory parent or guardian of the person: The representations contained herein are made under the penalties of false statement. ............................................................................................................. Guardian Ad Litem: .......................................................................................... Petitioner: Date: Date: [Any signature by a minor or incompetent petitioner must be approved by a guardian ad litem. C.G.S. § 45a-715.] PROPOSED STATUTORY PARENT/GUARDIAN(S) OF THE PERSON IF APPOINTED, I WILL ACCEPT THE POSITION OF TRUST. Signature ......................................................................................... Name [Type or print. Include maiden name, if applicable.] Address and zip code: Telephone number: DATE OF BIRTH: APPLICATION/TERMINATION OF PARENTAL RIGHTS PC-600 Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION/ TERMINATION OF PARENTAL RIGHTS PC-600 REV. 7/12 Page 5 STATE OF CONNECTICUT RECORDED(CONFIDENTIAL VOLUME): COURT OF PROBATE [For the legal effects of a Termination of Parental Rights Decree, see below.] IF APPOINTED, I WILL ACCEPT THE POSITION OF TRUST. Signature ......................................................................................... Name [Type or print. Include maiden name, if applicable. ] Address and zip code: Telephone number: DATE OF BIRTH: 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 an Affidavit of Consent to Termination of Parental Rights, JD-JM-60. C.G.S. § 45a-715. To waive personal service, formPC-633, Waiver of Personal Service Parental Rights Matters, must be filed.] DATE DULY ACKNOWLEDGED BEFORE ME ............................................................................................. Father: ............................................................................................. Judge, Ass't Clerk, Notary Public, Comm. Sup.Ct. ............................................................................................. Mother: ................................................................................................ Judge, Ass't Clerk, Notary Public, Comm. Sup.Ct. ............................................................................................. Guardian Ad Litem: ........................................................................................... 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. C.G.S. § 45a-715. [This statement applies in all cases where a minor is twelve years of age or older. Only complete the statement below if a statutory parent will be appointed.] I, the minor child, having attained the age of twelve years, of Children and Families. consent do not consent to being photo-listed with the Department ........................................................................................ 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 of its rights and responsibilities 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 to 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 FURTHERMORE, upon a decree of termination, the child will be legally free for adoption, and the parent will have no right to notice of the adoption proceedings nor any right to participate in the proceedings. APPLICATION/TERMINATION OF PARENTAL RIGHTS PC-600 Page 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL STATE OF CONNECTICUT DO NOT RECORD INFORMATION SHEET FOR PC-600, Application/ COURT OF PROBATE [Type or Print in Black Ink.] Termination of Parental Rights NEW 7/12 _____________________________________________________________________________________ Court of Probate, In the Matter of ,District. ,a minor child. The social security numbers of the parent(s) of the minor child are required in connection with this proceeding 1) Mother: Name: Social Security Number: 2) Father: Name: Social Security Number: 3) Proposed Guardian(s): a. Name: Social Security Number: b. Name: Social Security Number: American LegalNet, Inc. www.FormsWorkFlow.com