CUSTODIAN'S AFFIDAVIT/ IMMEDIATE TEMPORARY CUSTODY PC-510 REV. 9/91 STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink.] RECORDED(CONFIDENTIAL VOLUME): TO: COURT OF PROBATE, IN THE MATTER OF [Name, address, and zip code.] DISTRICT NO. DATE OF BIRTH OF MINOR CHILD LENGTH OF TIME AS CUSTODIAN OF MINOR CHILD CUSTODIAN[Name, address, zip code, and telephone number] State circumstances under which you obtained custody of the minor child. Give specific facts that would justify the conclusion that immediate temporary custody is necessary and that determination of the need for temporary custody cannot await notice of hearing. Any false statement made herein is punishable under the law. C.G.S. §45a-607(b)(1). ................................................................................... Custodian: [To give further details, use PC-180, Second Sheet.] SUBSCRIBED AND SWORN TO BEFORE ME DATE ................................................................................... Judge, Ass't Clerk, Notary Public, Comm. Sup. Ct. CUSTODIAN'S AFFIDAVIT/IMMEDIATE TEMPORARY CUSTODY PC-510 American LegalNet, Inc. www.FormsWorkFlow.com