Petition/Immediate Temporary Custody PC-501 REV. 10/1 CONFIDENTIAL Petition/Immediate Temporary Custody PC - 50 1 Page 1 of 5 RECEIVED: Instructions 1) An adult relative may use this form to petition for the appointment ofa minor child, if a petition for: a) removal of a guardian, b) termination of parental rights, or c) appointment of a guardian of a minor child who has no guardian has been filed with the court. This form may also be used by an attorney for a minor child or by an adult who is not a relative, but who has actual physical custody of the minor at the time the petition is filed. The petition should be filed in the court for the probate district in which the minor child resides, isA Custodian222s Affidavit/Immediate Temporary Custody, PC-510, must be filed with the petition unless 4)ForProbate Court Name District Number In the Matter of (NaMinor Child222s Date of Birth Address where minor child resides Address where minor child is located at time of filing petition (if different) Tribe and Reservation of Minor Child, if an Indian Child as defined by 25 U.S.C. section 1903 (Name and address.) Petitioner (Name, address and telephone numAdult relative (List relationship and date of birth) Adult with actual physical custody of minor child. (List date of birth and describe circumstances under which the minor came to be in the petitioner222s custody): Person(s) to be Removed as Guardian/Parental Rights Terminated. (For each person, list name, address, telephone number relationship to the child date of birth if a parent; whether in the 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 the person is legally incompetent.)e.Legally incompetent: Yes No 2. a. Relationship to minor child: b.If parent, date of birth:c.In military service of US or Allied Nation: Yes Nod.Indian tribe or reservation:e.Legally incompetentPetitioner ) Address where minor child American LegalNet, Inc. www.FormsWorkFlow.com Petition/Immediate Temporary Custody PC-501 REV. 10/1 CONFIDENTIAL Petition/Immediate Temporary Custody PC - 50 1 Page 2 of 5 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. Name of parent whose parental rights were previously terminated, if any Name of deceased parent (s) or guardians, if any The petitioner alleges that the whereabouts of the respondent(s) are unknown. The last-known address of the respondent(s) is: The following efforts have been made to obtain the current address for the respondent(s): Other Person(s) with Guardianship Rights. (For each person, list name, address, telephone numberrelationship to the child date of birth if a parent; whether parent is in the military service of United States or Allied Nation; Indian tribe and reservation, if a member as defined by 25 U.S.C. section 1903; and whether the person is legally incompetent.) Parent(s) whose guardianship rights have previously been removed by a court. (For each person, list name, address, telephone number relationship to the child date of birth; whether the parent is in military service of United States or Allied Nation; Indian tribe and reservation, if a member as defined by 25 U.S.C. section 1903; and whether the person is legally incompetent.) Minor Child is in the Current Physical Care of: (Name, address and telephone number. State relationship to minor child.) American LegalNet, Inc. www.FormsWorkFlow.com Petition/Immediate Temporary Custody PC-501 REV. 10/1 CONFIDENTIAL Petition/Immediate Temporary Custody PC - 50 1 Page 3 of 5 The petitioner represents that: A petition is pending in this court for the removal of one or both parents as guardians or for the removal of the guardian of the minor child; OR A petition is pending in this court for the termination of parental rights with respect to the minor child; OR The petitioner has reasonable grounds to believe that the minor child has no guardian of his or her person, and a petition for appointment of a guardian is pending. The petitioner further represents that: The minor child is in the current physical care of a person other than the parent or other guardian, subject to the petition for removal of guardianship or termination of parental rights. (If this box is checked, Custodian222s Affidavit, PC-510, must be filed with this petition.) AND The child was not taken or kept from the parent(s) or guardian(s), AND there is a substantial likelihood that the child will be removed from this jurisdiction prior to a hearing for temporary custody; OR To return the child to the parent(s) or guardian(s) would place the child in circumstances that would result in serious physical illness or injury, or the threat thereof, or imminent physical danger prior to a hearing for temporary custody; OR The minor child is hospitalized as a result of serious physical illness or serious physical injury and is in need of immediate medical or surgical treatment, the delay of which would be life-threatening, AND the parent(s) or guardian(s) refuses to consent or is unable to consent to such treatment. (If this box is checked, Physician's Certificate/Immediate Temporary Custody, PC-550, from two physicians must be filed with this petition.) OR The minor child is in the current physical care of the parent(s) or guardian(s), AND the minor child is hospitalized as a result of serious physical illness or serious physical injury and is in need of immediate medical or surgical treatment, the delay of which would be life-threatening, AND the parent(s) or guardian(s) refuses to consent or is unable to consent to such treatment. (If this box is checked, Physician'sCertificate/Immediate Temporary Custody, PC-550, from two physicians must be filed with this petition.) The petitioner further represents that the parent or other guardian has performed acts of omission or commission as set forth in C.G.S. section 45a-610: The minor child has been abandoned by the parent or guardian in the sense that the parent or guardian has failed to maintain a reasonable degree of interest, concern, or responsibility for the child222s welfare. The minor child has been denied the care, guidance, or control necessary for his or her physical, educational, moral, or emotional well-being as defined by law. The minor child has had physical injuries inflicted upon him or her by a person responsible for such child222s health, welfare, or care, or by a person given access to such child by such responsible person, other than by accidental means, or has injuries which are at variance with the history given of them or is in a condition which is the result of maltreatment such as, but not limited to, malnutrition, sexual molestation, deprivation of necessities, emotional maltreatment, or cruel punishment. The minor child has been neglected or uncared for, as defined in C.G.S. section 46b-120. AND BECAUSE OF SUCH ACTS, THE CHILD IS SUFFERING FROM SERIOUS PHYSICAL ILLNESS, SERIOUS PHYSICAL INJURY, OR THE IMMEDIATE THREAT THEREOF, OR IS IN IMMEDIATE PHYSICAL DANGER. American LegalNet, Inc. www.FormsWorkFlow.com Petition/Immediate Temporary Custody PC-501 REV. 10/1 CONFIDENTIAL Petition/Immediate Temporary Custody PC - 50 1 Page 4 of 5 The pet itioner alleges , which cause the child to suffer serious physical illness or serious physical injury, or the immediate threat thereof, or place him or her in immediate physical danger. The petitioner further represents that to the best of his or her knowledge and belief: The minor child has resided has not resided in Connecticut continuously for the last six months. There is a proceeding is not a 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 i