CONNECTICUT PROBATE COURTS Petition/Termination of Parental Rights PC - 600 REV. 1/17 CONFIDENTIAL Petition/Termination of Parental Rights PC - 600 Page 1 of 7 : Instructions: 1) A parent or guardian, or other authorized person or agency under C.G.S. section 45a-715, may use this form to petition for termination of parental rights of a parent or parents of a minor child. For a child born out of wedlock, the petition shall list any putative father as defined in C.G.S. section 45a-716 (b). 2)The petition should be filed in the court for the probate district in which the petitioner resides3)A statement of facts for each ground of termination, including consent, must be completed. See Page 4. 4)The following documents should be filed with the petition: a) A long-form birth certificate , b) JD-FM-164, Affidavit Concerning Children5)For more information, see C.G.S. sections 6 )Type or print the form in ink. Use an additional sheet , or Second Sheet, PC - 180, if more space is needed . Probate Court Name District Number In the Matter of Hereinafter referred to as the minor child . Place of Birth of Minor Child Birth Date of Minor Child Address where minor child resides Address where minor child is domiciled (if different) Address where minor child is located at time of filing petition (if different) Petitioner (Name, address and telephone number, the nature of the relationship to the minor child.) Parents of Minor Child (For each parent, list name, address, telephone number, date of birth, 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 parent is legally incompetent. Include any putative father of a child born out of wedlock. C.G.S. section 45a-716 (b) (2))2. a. Relationship to minor child: b.If parent, date of birth:c.In military service of US or Allied Nation: Yes Nod.Indian Hereinaft er referred to as the respondent(s). American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Petition/Termination of Parental Rights PC - 600 REV. 1/17 CONFIDENTIAL Petition/Termination of Parental Rights PC - 600 Page 2 of 7 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. (Provide a copy of the court decree.) The petitioner alleges that the whereabouts of the respondent (s) is 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): Guardian of the person, if not a parent (For each guardian, list name, address, telephone number and date of appointment as guardian.) Child-placing agency involved with the minor child, if not the petitioner (Name, address and telephone number.) The petitioner represents that: The parental rights of the person (s) indicated below should be terminated for one or more of the following grounds as provided by statute and as more fully described in the attached statement of facts for each ground for termination: consent(s) to termination of his or her parental rights with respect to minor child. (No further allegation is necessary against a consenting parent. However an Affidavit/ Consent to Termination of Parental Rights, JD-JM-60, must accompany this petition.) OR The child was abandoned by in the sense that the parent has failed to maintain a reasonable degree of interest, concern or responsibility as to the welfare of the child. American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Petition/Termination of Parental Rights PC - 600 REV. 1/17 CONFIDENTIAL Petition/Termination of Parental Rights PC - 600 Page 3 of 7 OR The child has been denied the care, guidance or control necessary for the child222s physical, educational, moral or emotional well-being, by reason of acts of parental commission or omission by . There has been a nonaccidental or inadequately explained serious physical injury to the child. There has been sexual molestation and exploitation, severe physical abuse or a pattern of abuse. Other acts of parental commission or omission as follows: OR There is no ongoing parent/child relationship, as defined in C.G.S. section 45a-717 (g), between the child and and to allow further time for the establishment or reestablishment of the parent/child relationship would be detrimental to the best interests of the child. OR The child is found to be neglected, abused or uncared for as those terms are defined under C.G.S. section 46b-120 AND has been in the custody of the Commissioner of the Department of Children and Families for at least 15 months, AND the parent,, has been provided specific steps to take to facilitate the return of the child to the parent pursuant to C.G.S. section 46b-129, AND the parent has failed to achieve such degree of personal rehabilitation as would encourage the belief that, within a reasonable time and considering the age and needs of the child, such parent could assume a responsible position in the life of the child. OR The child has been found in a prior proceeding by the Probate Court for the District of or the Superior Court to have been neglected, abused or uncared for as those terms are defined under C.G.S. section 46b-120, AND the parent has failed to achieve such degree of personal rehabilitation as would encourage the belief that, within a reasonable time and considering the age and needs of the child, such parent could assume a responsible position in the life of the child. OR The child is under seven years of age AND is neglected, abused or uncared for as those terms are defined in C.G.S. section 46b-120, AND the parent, , has failed, is unable or is unwilling to achieve such degree of personal rehabilitation as would encourage the belief that, within a reasonable time and considering the age and needs of the child, such parent could assume a responsible position in the life of the child, AND such parent222s parental rights of another child were previously terminated pursuant to a petition filed by the Commissioner of Children and Families. OR The parent, , has killed through deliberate, nonaccidental act another child of the parent OR has requested, commanded, importuned, attempted, conspired or solicited such killing OR has committed an assault through deliberate and nonaccidental act that has resulted in serious bodily injury of another child of the parent. OR The parent, , committed an act or acts that constitute sexual assault as described in sections 53a-70, 53a-70a, 53a-70b, 53a-70c, 53a-71, 53a-72a, 53a-72b or 53a-73a, and the assault resulted in the conception of the child. The parent, , was adjudged guilty of sexual assault under section 53a-70, 53a-70a, 53a-70b, 53a-70c, 53a-71, 53a-72a, 53a-72b or 53a-73a, and the assault resulted in the conception of the child. American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Petition/Termination of Parental Rights PC - 600 REV. 1/17 CONFIDENTIAL Petition/Termination of Parental Rights PC - 600 Page 4 of 7 Statement of facts in support of each ground for termination of parental rights alleged, including consent termination: American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Petition/Termination of Parental Rights PC - 600 REV. 1/17 CONFIDENTIAL Petition/Termination of Parental Rights PC - 600 Page 5 of 7 The petitioner further represents that the termination of parental rights of the parent(s), , is in the best interests of the child. 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 no 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 Departme