Petition for Review of DCF Permanency Plan for Child or Youth (Voluntary) PC-5011 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 review of the permanency plan for a child or youth voluntarily admitted to the department and placed in a foster home under C.G.S. section 17a-114 or in a facility licensed under C.G.S. section 17a-145. 2) The petition must be filed in the probate district that had jurisdiction over the approval of the initial permanency plan. The petition for review of the permanency plan must be submitted not more than 10 months after the child or youth was admitted to the department on a voluntary basis and annually thereafter. 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 Date of Out-of-Home Placement of Child or Youth Date of Last Review of Permanency Plan Name, Address and Telephone Number of Foster Home or Facility Licensed by the Department where Child or Youth Resides Name, Address and Telephone Number of Other Persons to Whom Notice Should be Given: Parents: Guardians, if any: Other: Petition for Review of DCF Permanency Plan for Child or Youth (Voluntary) PC-5011 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Petition for Review of DCF Permanency Plan for Child or Youth (Voluntary) PC-5011 NEW 10/15 THE PETITIONER REPRESENTS THAT: 1) The child or youth referenced above is under the age of 18. CONNECTICUT PROBATE COURTS RECORDED(CONFIDENTIAL): 2) The child or youth is receiving services voluntarily from the Department of Children and Families and was initially placed by the department in a foster home licensed pursuant to C.G.S. section 17a-114 or in a facility licensed pursuant to C.G.S. section 17a-145 on the date referenced above, and the Probate Court determined that the continuation of care was in the best interests of the child or youth. 3) C.G.S. section 17a-11 (e) requires that the court review the permanency plan for the child or youth, who has been placed out of the home, 10 months after admitting the child or youth on a voluntary basis and annually thereafter. A copy of the permanency plan is attached. 4) The continuation of care as outlined in the attached permanency plan is in the best interests of the child or youth. 5) The permanency plan is appropriate considering the following factors under C.G.S. section 17a-11 (f) (1), including the health and safety of the child or youth, the treatment and services that have been offered and provided and other efforts that have been made to promote the best interests of the child or youth: THE COMMISSIONER OF THE DEPARTMENT OF CHILDREN AND FAMILIES PETITIONS THE COURT FOR: A review and approval of the permanency plan, including the status of the child or youth, the efforts being provided, progress being made and the timeline to attain permanency in accordance with C.G.S. section 17a-11 (f). 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 Review of DCF Permanency Plan for Child or Youth (Voluntary) PC-5011 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com