CONNECTICUT Petition/Temporary Custody PC-502 REV. 10/1 CONFIDENTIAL Petition/Temporary Custody PC - 50 2 Page 1 of 4 RECEIVED: Instructions 1) An adult relative may use this form to petition for the appointment of a temporary custodian of 5) Type or print the form in ink. Use an additional sheet, or Second Sheet, PC-180, if more space is needed 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 incompetent: Yes No 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:Probate Court Name District Number In the Matter of (Name of minor child) Minor Child222s Date of Birth 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; Petitioner (Name, address and telephone number) PetitionerAdult 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): ress where minor child resides ress where minor child ress where minor child American LegalNet, Inc. www.FormsWorkFlow.com Petition/Temporary Custody PC-502 REV. 10/1 CONFIDENTIAL Petition/Temporary Custody PC - 50 2 Page 2 of 4 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 guardian (s), 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 number relationship 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.) CONNECTICUT American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Petition/Temporary Custody PC-502 REV. 10/1 CONFIDENTIAL Petition/Temporary Custody PC - 50 2 Page 3 of 4 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 the appointment of a guardian is pending. The parent(s) or other guardian(s) consent to an order of temporary custody of the minor child. [No further allegation is necessary against a consenting parent/guardian.] The petitioner further represents that the parent or other guardian has performed acts of omission or commission as set forth in C.G.S. sections 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 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. The petitioner 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 is is not a current protective order or restraining order involving any party. If so, please attach. The minor child is is not the subject of a pre-existing child support order. American LegalNet, Inc. www.FormsWorkFlow.com Petition/Temporary Custody PC-502 REV. 10/1 CONFIDENTIAL Petition/Temporary Custody PC - 50 2 Page 4 of 4 The petitioner further represents that it is in the best interest of the minor child that temporary custody of the minor child be granted to a proper person as provided in C.G.S. section 45a-607, pending determination of the: removal of parent as guardian matter termination of parental rights matter, or petition for appointment of a guardian for the minor child, who has no guardian. WHEREFORE the petitioner requests that an order for temporary custody for the minor child be granted to: [List name and relationship to minor child.] The representations made in this petition are made under penalty of false statement. Signature of Petitioner Type or Print Name Date Acceptance of Trust of Temporary Custodian(s) If appointed, I will accept the position of trust: Signature of Proposed Temporary Custodian Type or Print Name (Include all prior names . ) Date Address Phone Number Date of Birth Signatu re of Proposed Temporary Custodian Type or Print Name (Include all prior names . ) Date Address Phone Number Date of Birth Consent to Temporary Custody I consent to an order of temporary custody of the minor child. [A parent may waive personal service by filing a Waiver of Personal or Abode Service/Parental Rights Matter, PC-633.] Signature of Parent/Guardian Duly Acknowledged Before Me Type or Print Name Date Judge, Clerk, Public Notary, Comm. Sup. Ct. Signature of Parent/Guardian Duly Acknowledged Before Me Type or Print Name Date Judge, Clerk, Public Notary, Comm. Sup. Ct. CONNECTICUT American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL INFORMATION Petition/Temporary Custody PC - 502 CI REV. 10/17 FOR COURT USE ONLY Confidential Information/Petition/Temporary Custody PC - 50 2CI RECEIVED: Probate Court Name District Number In the Matter of ,a minor child. The social security numbers of the following persons are required in connection with this proceeding: 1)Parent(s) to be removed as guardian or whose parental rights may be terminated:a.Name: Social Security Number: b.Name: Social Security Number: 2)Proposed temporary custodian(s):a.Name: Social Security Number: b.Name: Social Security Number: CONNECTI