Free JD-JM-58 - Connecticut

MOTION/ORDER OF TEMPORARY CUSTODY/ORDER TO APPEAR
JD-JM-58 Rev. 12-08 C.G.S. § 46b-129(b) & (k), P.B. 33a-6 Address of Court Name of Child/Youth Name of Mother Name of Father Name of Legal Guardian (If any) Name of Putative Father (If any) If Parent(s) is/are Minor(s), Name(s) of Grandparent(s) or Guardian(s) Address of Child/Youth Address of Mother Address of Father Address of Legal Guardian Address of Putative Father

STATE OF CONNECTICUT SUPERIOR COURT JUVENILE MATTERS www.jud.ct.gov
Docket Number Date of Birth

Address(es) of Grandparent(s) or Guardian(s)

Motion
The child or youth has been placed in the care and custody of the Commissioner of Children and Families pursuant to at (time) section 17a-101g (96 hour hold) on (date) . Based on the allegations of the petition and verified affirmations of fact, the petitioner requests an ex parte Order of Temporary Custody/Order to Appear under section 46b-129(b) of the general statutes.
Name of Petitioner Signed (Petitioner) Address of Petitioner Relationship to Child Judge, Assistant Clerk, Notary, Commissioner of Superior Court

Sworn and Subscr bed Date Signed To Before Me On:

Order
The court finds: A. said child/youth is suffering from serious physical illness, or B. said child/youth is suffering from serious physical injury, or C. said child/youth is in immediate physical danger from surroundings. And As a result of said conditions, the child's/youth's safety is endangered and immediate removal from such surroundings is necessary to ensure the child's/youth's safety. II. Conditions or circumstances surrounding the care of said child/youth require that the respondent(s) appear before the court as set forth below to determine whether an order vesting temporary custody of said child/youth in a suitable agency or person should be issued pending disposition of the petition. I. Continuation in the home is contrary to the welfare of said child/youth. A. Reasonable efforts to prevent or eliminate the need for removal of said child/youth were made by the state. B. Reasonable efforts to prevent or eliminate the need for removal of said child/youth from the home were not possible. C. Reasonable efforts were not made. It is Hereby Ordered That: You, the parent/guardian, appear before the court as set forth below to determine whether an order stating that temporary custody of said child/youth should vest in a suitable agency or person should be issued pending disposition of the petition. The temporary care and custody of said child/youth shall be vested in: pending a hearing as set forth below on the confirmation of this order. And it is further ordered that the above-named mother/father/guardian be and hereby is/are summoned to appear before the court on the Hearing Date(s) set out below, at the address shown above, by having a proper officer leave a true and attested copy of this order and summons with them or at their usual place of abode, or if so ordered, by publication or mail and return same to the court on or before the date indicated. llI. IV.

Hearing Date - Preliminary Hearing On Temporary Custody Hearing Date - Petition Court Location
Publication For: Name of Judge

Date Date Court Location (Number, street, and town) Statutory Mail For: Signed (Judge)

Time of Hearing

.M.
Time of Hearing

.M.
Telephone Number Service on or Before (Date) Return Date Date Signed

(Continued)

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Return of Service
STATE OF CONNECTICUT
County of SS. Name of Person(s) Served

Docket Number

Date of Service

Then and there, I duly served the foregoing petition, order and summons on the above-named
Copy

Fees

leaving with (for in hand); or leaving at the usual place of abode (for abode) at The within and foregoing is a true and attested copy of the original petition, order, and summons.
Attest (Signature and title of proper officer)

Endorsement Service Travel Total

STATE OF CONNECTICUT
County of SS. Name of Person(s) Served Date of Service

Then and there, I duly served the foregoing petition, order and summons on the above-named respondent(s), by either (check one): leaving with (for in hand); or leaving at the usual place of abode (for abode) at The within and foregoing is a true and attested copy of the original petition, order, and summons.
Attest (Signature and title of proper officer)

Fees
Copy Endorsement Service Travel Total

STATE OF CONNECTICUT
County of SS. Name of Person(s) Served Date of Service

Then and there, I duly served the foregoing petition, order and summons on the above-named respondent(s), by either (check one): leaving with (for in hand); or leaving at the usual place of abode (for abode) at The within and foregoing is a true and attested copy of the original petition, order, and summons.
Attest (Signature and title of proper officer)

Fees
Copy Endorsement Service Travel Total

For Mail Service
County of

STATE OF CONNECTICUT
United States Post Office At (Town) SS. Date of Service

Then and there, by virtue hereof, I made service of the within petition, order and summons by depositing a true and attested copy by United States Post mail, postage prepaid, addressed to restricted delivery, return receipt requested; or first class mail; or certified mail, return receipt requested. The within and foregoing is a true and attested copy of the original petition, order, and summons.
Attest (Signature and title of proper officer)s

Fees
Copy Endorsement Service

Travel Total

JD-JM-58 Rev. 12-08

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