Petition for Order Authorizing DSS to Enter the Premises of an Elderly Person for a Protective Services Assessment PC-909 NEW 10/15 CONNECTICUT PROBATE COURTS RECEIVED: Instructions: 1) The commissioner of social services may use this form to petition the court for an order authorizing the commissioner or his designees to enter the premises of an elderly person for the sole purpose of an assessment when the commissioner has reasonable cause to believe that the elderly person may be in need of protective services, but the department has been denied access by the elderly person or another individual. 2) The petition should be filed in the court for the probate district in which the elderly person resides or is located at the time of filing the petition. 3) For more information, see C.G.S. section 17b-464. 4) Type or print the form in ink. Use an additional sheet if more space is needed. District Number Probate Court Name In the Matter of (List name and residence address of the elderly person who may be in need of protective services.) Present address of elderly person (if different) Petitioner (List name and DSS office address.) Person (s) preventing access to elderly person (List name and address of each person.) THE PETITIONER REPRESENTS THAT: 1) The commissioner of social services has reasonable cause to believe that the above-named elderly person may be in need of protective services, and the elderly person or the above-named person(s) has denied the department access to the premises where the elderly person resides or is located. 2) The commissioner's belief that the elderly person may be in need of protective services is based on the following facts: (If the allegations below are not based on the commissioner's personal knowledge of alleged abuse, neglect, exploitation or abandonment of the elderly person, include the source of the information and/or attach an affidavit of the person having such knowledge.) 3) The following efforts have been made to enter the premises of the elderly person who may need protective services: Petition for Order Authorizing DSS to Enter Premises of Elderly Person for Protective Services Assessment PC-909 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Petition for Order Authorizing DSS to Enter the Premises of an Elderly Person for a Protective Services Assessment PC-909 NEW 10/15 CONNECTICUT PROBATE COURTS The commissioner has submitted a prior petition to enter the premises of the elderly person or for similar relief, which petition was approved denied. If denied, please provide any new facts in support of the current petition. 4) The following persons will conduct the assessment of whether the elderly person is in need of protective services (List the names, titles and agency affiliations): 5) The assessment will be conducted in the following manner: THE PETITIONER REQUESTS THAT: The court enter an order authorizing the commissioner of social services or designee to enter the premises of the abovenamed elderly person for the sole purpose of assessing whether the elderly person is in need of protective services. It is further requested that the order authorize the commissioner or designee to be accompanied by a police officer or other law enforcement official, and any other persons the commissioner determines necessary, including those individuals listed above, to conduct the assessment. The representations made in this petition are made under the penalty of false statement. Signature of Petitioner Title Type or Print Name Date Petition for Order Authorizing DSS to Enter Premises of Elderly Person for Protective Services Assessment PC-909 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com