Request for Review/ Modification of Visitation PC-5012 REV. 10/16 RECEI VED: CO N N E C T I C U T P R O B A TE C O U R T S RECORDED (CONFIDENTIAL): Instructions: 1) Any person who has been removed as guardian of a minor child, any relative of the minor child or any parent or guardian who has been denied temporary custody of a minor child pending the hearing on a removal or termination of parental rights petition who has been granted visitation rights to the minor child or children may use this form to petition the court for the review or modification of the visitation order. 2) The petition shall be filed in the probate district that has jurisdiction over the children's matter. 3) Type or print the form in ink. Use Second Sheet, PC-180, or an additional sheet, if more space is needed. Probate Court Name District Number In the Matter of (List name of minor child and address and telephone number where minor currently resides.) Hereinafter referred to as the minor. Minor's Date of Birth Petitioner (List name address, telephone number, date of birth and relationship to minor.) _ (Provide copy of court order or decree.) Visitation granted on Person(s) Who Have Rights with Respect to the Minor Child. (If a minor, incompetent or in the military, so indicate. Give last known address, telephone number and date of birth.) Mother (If whereabouts are unknown, provide last known address.) Father (If whereabouts are unknown, provide last known address.) Guardian(s) Is there a current safety agreement or a protective order in place? Request for Review/Modification of Visitation Yes No. If "Yes," attach a copy. PC-5012 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Request for Review/ Modification of Visitation PC-5012 REV. 10/16 CO N N E C T I C U T P R O B A T E C O U R T S RE COR DE D ( C O N F I D E N T I A L ) Explain Reason for Requesting a Review or Modification of Visitation. THE PETITIONER REPRESENTS that: There is no proceeding pending or contemplated in Connecticut or any other state affecting the custody of the minor. There is a proceeding pending or there has been a past proceeding in Connecticut or other state affecting the custody of the minor. (If checked, complete and attach form JD-FM-164, Affidavit Concerning Children.) WHEREFORE, the petitioner requests that: The court review and/or modify visitation concerning this minor child. The representations made in this petition are made under the penalty of false statement. Signature of the Petitioner Date Request for Review/Modification of Visitation American LegalNet, Inc. www.FormsWorkFlow.com PC-5012 Page 2 of 2