Petition for Determination Re: Continuance of DCF Care of Child or Youth/Case Service Plan or Permanency Plan (Voluntary) PC-5010 NEW 10/15 RECEIVED: CONNECTICUT PROBATE COURTS RECORDED(CONFIDENTIAL): Instructions: 1) The Commissioner of the Department of Children and Families may use this form to petition for a determination that the continuance of care of a child or youth voluntarily admitted to the department is in the best interests of the child or youth and that a case service plan or permanency plan is appropriate. 2) The petition must be filed in the probate district in which the child or youth resides not more than 120 days after the child or youth has been admitted to the department on a voluntary basis. 3) For more information, see C.G.S. section 17a-11. 4) Type or print the form in ink. District Number Probate Court Name In the Matter of (List name and address.) Date of Birth of Child or Youth Hereinafter referred to as the child or youth. Petitioner (Commissioner of Department of Children and Families or designee and address.) Date Child or Youth was Admitted to the Department on a Voluntary Basis Name, Address and Telephone Number of Foster Home or Department-Licensed Facility where Child or Youth Resides Name, Address and Telephone Number of Other Persons to Whom Notice Should be Given Parents: Guardians, if any: Other: THE PETITIONER REPRESENTS THAT: 1) The child or youth referenced above is under the age of 18. 2) A parent or guardian of the child or youth resides in this probate district, and jurisdiction appertains to this court. Petition for Determination re: Continuance of DCF Care of Child or Youth (Voluntary) PC-5010 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Petition for Determination Re: Continuance of DCF Care of Child or Youth/Case Service Plan or Permanency Plan (Voluntary) PC-5010 NEW 10/15 CONNECTICUT PROBATE COURTS RECORDED(CONFIDENTIAL): 3) The child or youth was admitted to the care of the Department of Children and Families on a voluntary basis on the date referenced above. 4) The child or youth receiving services voluntarily from the Department of Children and Families: continues to reside with a parent or guardian and is not in an out-of-home placement. A copy of the case service plan for the child or youth is attached. has been placed by the department in a foster home licensed pursuant to C.G.S. section 17a-114 or in a facility licensed pursuant to section 17a-145. A copy of the permanency plan for the child or youth is attached. 5) The continuation of care as outlined in the attached case service plan or permanency plan is in the best interests of the child or youth. 6) The case service plan or permanency plan is appropriate considering the health and safety of the child and youth and the other considerations under C.G.S. section 17a-11. THE COMMISSIONER OF THE DEPARTMENT OF CHILDREN AND FAMILIES PETITIONS THE COURT FOR: A determination that the continuation of care and services by the Department of Children and Families on a voluntary basis is in the best interests of the child or youth, and the attached case service plan or permanency plan is appropriate and be approved, considering the factors under C.G.S. sections 17a-11 (d) (2) and 17a-11 (f), respectively. 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 Determination re: Continuance of DCF Care of Child or Youth (Voluntary) PC-5010 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com