CONNECTICUT PROBATE COURTS Petition/Consent Termination of Parental Rights AND Stepparent, Co-Parent or Relative Adoption PC-601 REV. /1 RECEIVED : Instructions: 1) A parent or guardian, or other authorized person or agency under C.G.S. section 45a-715, may use this 2)The petition should be filed in the court for the probate district in which the adoptive parent resides or inthe case of a minor who is under the guardianship of any child care facility or child-placing agency, in the district in which the main or local office of the agency is located. 5 )Type or print the form in ink. Use an additional sheet , or Second Sh eet, PC - 180, if more space is needed . Probate Court Name District Number In the Matter of (inor222s name and address where minor is residing. Place of Birth of Minor Child Birth Date of Minor Child Tribe and Reservation of Minor Child, if an Indian Child as defined by 25 U.S.C. section 1903 (ame and address) Jurisdiction based on: Petitioner (ame, address and telephone number and 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. e.Legally incompetent Yes No Petition/Consent Termination of Parental Rights AND Stepparent, Co-Parent or Relative Adoption PC-601 Page 1 of CONFIDENTIAL American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Petition/Consent Termination of Parental Rights AND Stepparent, Co-Parent or Relative Adoption PC-601 REV. /1 2. a. Relationship to minor child: b.Date of birth:c.In military service of US or Allied Nation: Yes Nod.Indian tribe or reservation:e.Legally incompetent Yes No Hereinafter referred to as the respondent (s). 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.) Adoptive Parent (s) (ame, address telephone number and the nature of the relationship to the minor child) Guardian of the person of the minor, if not a parent (For each guardian, list name, address, telephone number date of appointment as guardian.) Child-placing agency involved with the minor child, if not the petitioner (ame, address and telephone number) The petitioner represents that: consent(s) to termination of his or her parental rights with respect to minor child. (Affidavit/ Consent to Termination of Parental Rights, JD-JM-60, and a statement of facts must accompany this petition.) d (Check one of the following.) The sole parent of the minor child has entered into an Adoption Agreement for the adoption of the minor child with his or her spouse. The sole parent is not relinquishing parental rights to the child. The sole parent of the child has entered into an Adoption Agreement for the adoption of the minor child with a person who shares parental responsibility for child with such parent. The sole parent is not relinquishing parental rights to the child. The guardian (s) of the person of the minor child have entered into an Adoption Agreement for the adoption of the minor child with the adoptive parent (s), one of whom is a relative by blood or adoption, descended from a common ancestor not more than three generations removed from the minor child. Petition/Consent Termination of Parental Rights AND Stepparent, Co-Parent or Relative Adoption PC-601 Page 2 of CONFIDENTIAL American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Petition/Consent Termination of Parental Rights AND Stepparent, Co-Parent or Relative Adoption PC-601 REV. /1 The information contained in the Adoption Data Sheet, PC-680 and other documents submitted with the petition is true and complete to the best knowledge and belief of the petitioner. The termination of parental rights of the parent(s), , and adoption by the adoptive 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 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. WHEREFORE, the petitioner requests that the court terminate the parental rights of , and approve the Adoption Agreement on file. The petitioner further requests that the court change the name of the minor child to: . The representations made in this petition are made under the penalty of false statement. Signature of Petitioner Type or Print Name Date Petition/Consent Termination of Parental Rights AND Stepparent, Co-Parent or Relative Adoption PC-601 Page 3 of CONFIDENTIAL American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Petition/Consent Termination of Parental Rights AND Stepparent, Co - Parent or Relative Adoption PC - 601 REV. 10/16 egal Effects of a Termination of Parental Rights Decree Termination of parental rights means 223the complete severance by court order of the legal relationship, with all of its rights and responsibilities between the child and his parent or parents so that the child is free for adoption except it shall not affect the right of inheritance of the child or the religious affiliation of the child.224 C.G.S. section 45a-707(8). (Inheritance rights cease upon adoption.) No action taken with respect to the termination of parental rights of one parent affects the parental rights of the other parent. Upon a decree of termination of parental rights, the parent will NO LONGER have the following rights and responsibilities with respect to the minor child who is the subject of the decree: The legal right to custody, guardianship or control of the minor child. The parent will have no legal right tocare for the minor child or to make any decisions on behalf of the minor child.The legal right to the minor child's birth certificate.The legal right to any state and federal benefits the parent may have been receiving for the minor child.The legal responsibility to support the minor child and to pay for the minor child's maintenance, medical andother expenses, but the parent MAY be responsible for support of the minor child until the effective date of thetermination.The legal responsibility to care for the minor child or make any decisions on his or her behalf.Furthermore, upon a decree of termination, the minor child will be legally free for adoption, and the parent will have no right to notice of the adoption proceedings nor any right to participate in the proceedings. Petition/Consent Termination of Parental Rights AND Stepparent, Co-Parent or Relative Adoption PC-601 Page 4 of CONFIDENTIAL Joinder and Consent of Minor Child I, the undersigned minor child, being at least 12 years of age, do join in the petition for termination of parental rights and consent to adoption by the proposed adoptive parent (s). C.G.S. sections 45a-715 and 45a-724. Signature of Minor Child Duly Acknowledged Before Me Type or Print Name Date Judge, Clerk, Public Notary, Comm. Sup. Ct. Consent to Termination I consent to the termination of my parental rights with respect to the minor child. (Any consent to termination of parental rights must be accompanied by an Affidavit/ Consent to Termination of Parental Rights, JD-JM-60. C.G.S. section 45a-715. A parent may wa