CONNECTICUT PROBATE COURTS Petition/ Appointment of Statutory Parent PC - 60 2 REV. 7/18 Instructions:1) A guardian of the person of a minor child or a duly authorized officer of any child-care facility or child- placing agency may use this form to petition for the appointment of a statutory parent who may further petition the court for authority to give the child in adoption. 2)The petition must be filed in duplicate in the court for the probate district in which the petitioner orminor child resides or in the district where the main or local office of the petitioner or proposed statutory parent is located. 3)The following documents should be filed with the petition: a) A certified long-form birth certificate,b)Adoption Data Sheet, PC-680, c) documents including affidavits, certified decrees and/or certifieddeath certificates in support of the petitioner222s representation that the minor child is free for adoption. 4)For more information, see C.G.S. sections 45a-718, 45a-724 and 45a-725. 5 )Type or print the form in ink. Use an additional sheet , or Second Sheet, PC - 180, if more space is needed . Probate Court Name District Number In the Matter of Date of Birth of Minor Child Place of Birth of Minor Child Petitioner Jurisdiction based on: Tribe and Reservation of Minor Child, if an Indian Child as defined by 25 U.S.C. section 1903 Guardian of Minor Child Proposed Statutory Parent of Minor Child ( American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Petition/ Appointment of Statutory Parent PC - 60 2 REV. 7/18 The petitioner represents that: The p etitioner further represents that to the best of his or her knowledge and belief: WHEREFORE, the petitioner requests The representations made in this petition are made under the penalty of false statement. If appointed, the statutory parent will accept the position of trust: American LegalNet, Inc. www.FormsWorkFlow.com