CONNECTICUT Petition/Appointment of Permanent Guardian PC-505 REV. /1 RECEIVED: nstructions: 1) A guardian appointed by the Probate Court or a person a petition for removal of the parent may use this form to petition for the appointment of a permanent guardian. 2)The petition should be filed in the court for the probate district in which a petition for the removal ofguardian is filed or with the Probate Court that previously appointed the guardian of the minor child. Also file Confidential Information Sheet, PC-505C, which is the last page of this petition. 3)For more information, see C.G.S. section 45a-Probate Court Name District Number In the Matter of (List minor222s name and address.) Hereinafter referred to as the minor childTribe and Reservation of Minor Child, if an Indian Child as defined by 25 U.S.C. section 1903 (List name and address.) Petitioner (List name, address and telephone number.) Petitioner is: A guardian of the person of the minor child previously Parent(s) of Minor Child (For each parent, list name, address, telephone number, date of birth, whether in military service of United States or Allied Nation (50 U.S.C. App. 520), Indian tribe and reservation, if a member as defined by 25 U.S.C. section 1903, and whether thee.Legally incompetent Yes No CONFIDENTIAL American LegalNet, Inc. www.FormsWorkFlow.com Petition/Appointment of Permanent Guardian PC-505 REV. /1 If a parent listed above is a minor or legally incompetent, list the parents or guardian/conservator for the parent. (Include the name, address, telephone number and relationship.) 1. 2. The mother was removed as guardian of the person of the minor chld by the Probate Court, District of by decree dated. The father was removed as guardian of the person of the minor child by the Probate Court, District of by decree dated. A petition to remove the mother/father as guardian of the person of the minor accompanies this petiton for appointment of a permanent guardian of the person of the minor child. The petitioner alleges that the whereabouts of the parent (s) is unknown. The following efforts have been made to obtain the current address for the parent (s): Guardian of the person, if not a parent or the petitioner (For each guardian, list name, address, telephone number and date of appointment as guardian.) The petitioner further represents that to the best of his or her knowledge and belief: There is a proceeding is no proceeding pending or contemplated in Connecticut or any other state affecting the custody of the minor child. There has been a proceeding has not been a proceeding in the past in Connecticut or any other state affecting the custody of the minor child. 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 is is not the subject of a pre - existing child support order. Petition/Appointment of Permanent Guardian PC-505 Page 2 of 5 CONFIDENTIAL CONNECTICUT American LegalNet, Inc. www.FormsWorkFlow.com Petition/Appointment of Permanent Guardian PC-505 REV. /1 The petitioner represents that: The appointment of as permanent guardian of the person of the minor child is in the best interest of the minor child AND at least one of the following statements is true: consent(s) to the appointment of the permanent guardian. The child was 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. The child has been denied the care, guidance or control necessary for the child222s 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. There is no ongoing parent/child relationship, as defined in C.G.S. section 45a-717 (g), between the child and and to allow further time for the establishment or reestablishment of the parent/child relationship would be detrimental to the best interest of the child. The child is found to be neglected, abused or uncared for as those terms are defined under C.G.S. section 46b-120 AND has been in the custody of the Commissioner of the Department of Children and Families for at least 15 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. section 46b-129, 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. The child has been fo und in a prior proceeding by the Probate Court for the Distr ict of or the Superior Court to have been neglected, abused or uncared for as those terms are defined under C.G.S. section 46b-120, 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. The child is under seven years of age AND is neglected, abused or uncared for as those terms are defined in C.G.S. section 46b-120, AND the parent, , has failed, is unable or is unwilling 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, AND such parent222s parental rights of another child were previously terminated pursuant to a petition filed by the Commissioner of Children and Families. 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 of another child of the parent. The parent, , committed an act or acts that constitute sexual assault as described in sections 53a-70, 53a-70a, 53a-70b, 53a-70c, 53a-71, 53a-72, 53a-72b or 53a-73a, and the assault resulted in the conception of the child. The parent, , was adjudged guilty of sexual assault under section 53a-70, 53a-70a, 53a-70b, 53a-70c, 53a-71, 53a-72, 53a-72b or 53a-73a, and the assault resulted in the conception of the child. Petition/Appointment of Permanent Guardian PC-505 Page 3 of 5 CONFIDENTIAL CONNECTICUT American LegalNet, Inc. www.FormsWorkFlow.com Petition/Appointment of Permanent Guardian PC-505 REV. /1 The petitioner further represents that: The minor child has resided with the proposed permanent guardian for at least one year. Adoption of the minor child is not possible or appropriate. The minor child is at least 12 years old and consents to the appointment of the proposed permanent guardian of the person. The minor child is under 12 years of age, and the proposed permanent guardian is a relative or is already serving as the permanent guardian of at least one of the siblings of the minor chld. The proposed guardian is suitable and committed to assuming the rights and responsibilities as permanent guardian for the minor child until the minor child reaches the age of majority. WHEREFORE, the petitioner requests that the court appoint as permanent guardian of the person of the minor child. The representations made in this petition are made under penalty of false statement. Signature of Petitioner Type or Print Name Date Proposed Permanent Guardian(s) If appointed permanent guardian, I will accept the position of trust: Signature Type or Print Name Date of Birth Relationship to Minor, if any Address Telephone Number Date Signature Type or Print Name Date of Birth Relationship to Minor, if any Address Telephone Number Date Petition/Appointment of Permanent Guardian