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Application Temporary Custody PC-502 - Connecticut
| Application Temporary Custody Form. This is a Connecticut form and can be used in Probate Statewide . |
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APPLICATION TEMPORARY CUSTODY PC-502 REV. 7/12 Page 1 of 3 STATE OF CONNECTICUT RECORDED(CONFIDENTIAL COURT OF PROBATE [Type or print in black ink. File in duplicate. Complete Confidential Information Sheet for PC-502 on last page.] DISTRICT NO. VOLUME): TO: COURT OF PROBATE, IN THE MATTER OF [Name, address where residing, and zip code.]Hereinafter referred to as the minor child. MINOR CHILD'S BIRTH DATE TRIBE AND RESERVATION of minor child, if an Indian child as defined by P.L. 95-608, 25 U.S.C. 1901, et seq. [Name and address] PETITIONER [Name, address. zip code, telephone number,and legal status of petitioner (e.g. adult relative, counsel for minor). If adult relative, give date of birth. If counsel for minor, also list juris number.] PERSON(S) TO BE REMOVED AS /GUARDIAN/TERMINATED [Name(s), address(es), zip code(s), telephone number(s), and Indian tribe and reservation if a member as defined by P.L. 95-608, 25 U.S.C. 1901, et seq. If parent, also give date of birth.] Hereinafter referred to as the respondent(s) OTHER PERSON(S) WITH GUARDIANSHIP RIGHTS [Name(s), address(es), zip code(s) and telephone number(s) and Indian tribe and reservation if a member as defined by P.L. 95-608, 25 U.S.C. 1901, et seq.] RELATIONSHIP TO MINOR CHILD MINOR CHILD IS PRESENTLY IN THE CUSTODY OF [Name, address, zip code and telephone number.] RELATIONSHIP TO MINOR CHILD THE PETITIONER REPRESENTS that: An application is pending in this court for the removal of one or both parents as guardians or for the removal of the guardian of said minor child; OR An application is pending in this court for the termination of parental rights with respect to said minor child; OR The petitioner has reasonable grounds to believe that said minor child has no guardian of his or her person. The parent(s) or other guardian(s) consent to the minor child's temporary removal. [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.§45a-610: The minor child has been abandoned by the parent in the sense that the parent has failed to maintain a reasonable degree of interest, concern, or responsibility for the child's welfare. C.G.S. § 45a-610(2). The minor child has been denied the care, guidance, or control necessary for physical, educational, moral, or emotional well-being as defined by law. C.G.S. § 45a-610(3). The minor child has had physical injuries inflicted upon him or her by a person responsible for such child's 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. C.G.S. § 45a-610(4). 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. APPLICATION/TEMPORARY CUSTODY PC-502 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION/ TEMPORARY CUSTODY PC-502 REV. 7/12 Page 2 of 3 STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink. File in duplicate.] RECORDED(CONFIDENTIAL VOLUME): THE PETITIONER ALLEGES the following specific actions, omissions, etc., 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. Included are dates, times, and places.[To give further details, use Second Sheet, PC-180.] THE PETITIONER FURTHER REPRESENTS that to the best of his or her knowledge and belief: The following respondent(s) is/are under a legal disability: No respondent(s) is under a legal disability. The following respondent(s) is/are in the military service of the United States or Allied Nation (Title 50 Appendix, U.S. C.520). No respondent(s) is in the military service. There is a no proceeding pending or contemplated in Connecticut or any other state affecting the custody of the minor child. C.G.S. §§ 52-231a and 46b-115 et seq. [Complete and attach form JD-FM-164, Affidavit Concerning Children.] There has been has not been a proceeding in the past in Connecticut or any other state affecting the custody of the minor child. C.G.S. § 52-231a and 46b-115 et seq. The minor child is is not the subject of a pre-existing child support order. 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. has has not resided in Connecticut continuously for the last six months. C.G.S. § 46b-115 et seq. The minor child APPLICATION/TEMPORARY CUSTODY PC-502 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION/ TEMPORARY CUSTODY PC-502 REV. 7/12 Page 3 of 3 STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink. File in duplicate. RECORDED(CONFIDENTIAL VOLUME): 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. § 45a-610, pending the determination of the aforesaid matter. WHEREFORE THE PETITIONER REQUESTS that an order for temporary custody for the minor child be granted to: [Give relationship to minor child, if any.] The representations contained herein are made under the penalties of false statement. Date: ........................................................................................ Petitioner: PROPOSED TEMPORARY CUSTODIAN(S) IF APPOINTED, I WILL ACCEPT THE POSITION OF TRUST. Signature .............................................................................................................................................. Name [Type or print. Include maiden name, if applicable.] Address and zip code: Telephone Number: IF APPOINTED, I WILL ACCEPT THE POSITION OF TRUST. Dateof birth: Signature .............................................................................................................................................. Name [Type or print. Include maiden name, if applicable.] Address and zip code: Telephone Number: Dateof birth: CONSE
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