Petition /Appointment of Voluntary Guardian of Person Age 18 through 20 PC-5013 REV. 4/19 CONNECTICUT PROBATE COURTS CONFIDENTIAL Petition/Appointment of Voluntary Guardian of Person Age 18 through 20 PC-5013 Page 1 of 2 In the Matter of: (Name of minor child) Hereinafter referred to as the minor Date of Birth of Minor Address where minor resides Address where minor is domiciled (if different) Address where minor is located at time of filing petition (if different) RECEIVED: Instructions : 1) Any adult person may use this form to petition the court to a ppoint a guardian of a person who is unmarried and (a) at least 18 but less than 21 years of age, (b) dependent on a competent caregiver, (c)consents to the appointment or continuation of a guardian of the person after attaining age 18, and (d)is filing with this petition, or has previously filed, a Petition/Special Immigrant Juvenile Findingsunder 8 USC 1101, PC-609, pursuant to C.G.S. section 45a-608n. The unmarried person is defined as a223minor or minor child224 under C.G.S. section 45a-616 (f) (2). 2)The petition shall be filed in the probate district in which the minor resides, is domiciled or is locatedat the time the petition is filed. Also file PC-5013CI, which is the last page of this petition. 3)For more information, see C.G.S. sections 45a-608n, 45a-616 and 45a-617. 4 ) Type or print the form in ink. Use an additional sheet , or PC - 180, if more space is needed. Probate Court Name District Number Petitioner (Name, address and telephone number) Mother/Parent (Name, address and telephone number) Deceased on Parental rights terminated on (Provide death certificate or court decree.) Father/Parent (Name, address and telephone number) Deceased on Parental rights terminated on (Provide death certificate or court decree.) Proposed Guardian (s) ( N ame, address , telephone number and relationship to minor, if any) Other persons to whom notice should be given (Names, addresses and relationship to the minor) American LegalNet, Inc. www.FormsWorkFlow.com Petition /Appointment of Voluntary Guardian of Person Age 18 through 20 PC-5013 REV. 4/19 CONNECTICUT PROBATE COURTS CONFIDENTIAL In the Matter of: (Name of minor child) Hereinafter referred to as the minor Petition/Appointment of Voluntary Guardian of Person Age 18 through 20 PC-5013 Page 2 of 2 THE PETITIONER REPRESENTS that: The minor resides in the probate district. The minor is unmarried and at least 18 but less than 21 years of age. The minor has no parent with guardianship rights or court-appointed guardian of the person. is the sole parent of the minor. he minor is dependent on the proposed guardian, who is a competent caregiver and has the ability to meet, on a continuing day-to-day basis, the physical, emotional, moral and educational needs of the minor and has established a relationship with the minor. (Include a description of proposed guardian222s relationship with minor.) The minor consents to the appointment or continuation of a guardian after attaining the age of 18. The guardian and minor have filed a petition for special immigrant juvenile findings pursuant to C.G.S. section 45a-608n. The appointment of the proposed guardian(s) of the person of the minor is/are in the best interests of the minor. THEREFORE, the petitioner requests that: The court appoint the proposed guardian(s) listed above as guardian(s) of the person of the minor, the petitioner having filed a petition for special immigrant juvenile findings pursuant to C.G.S. section 45a-608n. The representations made in this petition are made under penalty of false statement. Signature of the Petitioner Date If appointed, I/we will accept the position of trust as guardian(s). Signature Signature Type or Print Name Type or Print Name Date of Birth Date of Birth Consent of Minor to Appointment of Guardian I consent to the appointment of the proposed guardian(s) or to the continuation of the guardianship after attaining age 18: Signature Acknowledged before me: Judge/Clerk/Notary Public/Comm. Sup. Ct. Type or Print Name Date American LegalNet, Inc. www.FormsWorkFlow.com Confidential Information/Petition/ Appointment of Voluntary Guardian of Person Age 18 through 20 PC - 5013CI C ONFIDENTIAL INFORMATION/ CONNECTICUT PROBATE COURTS Petition/Appointment of Voluntary Guardian of Person Age 18 through 20 PC - 50 13 C I REV. 4 /1 9 FOR COURT USE ONLY RECEIVED: Probate Court Name District Number In the Matter of , a minor The social security numbers of the following persons are required in connection with this proceeding: 1)Mother: Name Maiden Name (If applicable) Social Security Number 2)Father: Name Social Security Number 3)Proposed Guardian(s): a. Name Maiden Name (If applicable) Social Security Number b. Name Maiden Name (If applicable) Social Security Number American LegalNet, Inc. www.FormsWorkFlow.com