Free PC-600 - Connecticut

APPLICATION/ TERMINATION OF PARENTAL RIGHTS PC-600 REV. 10/00 Page 1

STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink .File in duplicate .] [Attach certified copy of birth certificate.] [If any information is unknown, so state in each box.]

RECORDED (CONFIDENTIAL VOLUME):

TO: COURT OF PROBATE, DISTRICT OF IN THE INTEREST OF [Name, present address, zip code, sex]

DISTRICT NO. PLACE OF BIRTH OF MINOR CHILD DATE OF BIRTH OF MINOR CHILD

a person under 18 years of age, hereinafter referred to as the minor child. The minor child is presently or was formerly the recipient of state Party whose parental rights are to be terminated is assistance. under a court order to pay child support. Jurisdiction based on: Petitioner or minor child resides in the probate district. Minor child is under the guardianship of a duly-licensed child care or child-placing agency, which has an office in the probate district. PETITIONER [Name, address, zip code, telephone number, the nature of the relationship to minor child and legal status of petitioner. C.G.S. §45a-715.]

PARENT(S) OF MINOR CHILD [Name(s), address(es), social security number(s), and tribe and reservation if American Indian as defined in P.L. 95-608] MOTHER: MOTHER'S DATE OF BIRTH

FATHER: [Include putative father named by the mother.]

FATHER'S DATE OF BIRTH

The petitioner represents that the whereabouts of the parent(s) or putative father are unknown. [If this box is checked, complete affidavit section at bottom of Page 2.] IF PARENT(S) TO BE TERMINATED IS A MINOR, LIST THE PARENT OR GUARDIAN OF THE MINOR PARENT. [Name(s), address(es), zip code(s), telephone number(s), and relationship]

GUARDIAN OF PERSON OF MINOR CHILD, if other than parent, and GUARDIAN AD LITEM APPOINTED IN PRIOR PROCEEDING(S), if any. [Name(s), address(es), zip code(s), and telephone number(s)]

TRIBE AND RESERVATION of minor child, if an American Indian as defined in P.L. 95-608. [Name, address, and zip code]

AGENCY THAT PLACED THE CHILD IN CURRENT PLACEMENT. [Name, address, and zip code]

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APPLICATION/ STATE OF CONNECTICUT RECORDED (CONFIDENTIAL VOLUME): TERMINATION OF COURT OF PROBATE PARENTAL RIGHTS PC-600 REV. 10/00 Page 2 [For legal effects of a Termination of Parental Rights Decree, see page 3.] THE PETITIONER REPRESENTS that said MINOR CHILD presently resides in the town named above, was born on the date written above, and the persons who may have parental rights are as stated above, AND THAT the parental rights of the person(s) indicated below should be terminated for the following reasons, as provided by statute. [Attached hereto and made a part hereof is a statement of facts made under oath relating to each ground for termination. C.G.S. §45a-717. See notice on reverse.] THE PETITIONER REPRESENTS that the termination of the parental rights of is in the best interests of the child, AND THAT consent(s) to termination of their parental rights with respect to the minor child. [No further allegation is necessary against a consenting parent. However, an Affidavit of Consent to Termination of Parental Rights, JD-JM-60, and a statement of facts related to this ground for termination must accompany this application.] OR The child has been abandoned by inthe sense that the parent has failed to maintain a reasonable degree of interest, concern, or responsibility as to the welfare of the child. OR The child has been denied the care, guidance, or control necessary for the child's 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. OR There is no ongoing parent/child relationship as defined in C.G.S. §45a-717(g), 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 or uncared for AND has been in the custody of the Commissioner of the Department of Children and Families for at least fifteen 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. §46b-129, as amended, 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 for the Judicial District of to have been neglected or uncared for, 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 or uncared for, AND the parent of the child has failed, is unable, or is unwilling to achieve such degree of personal rehabilitation as would encourage the belief that, within a reasonable amount of time, considering the age and needs of the child, such parent could assume a responsible position in the life of the child, AND such parent's 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 to another child of the parent. OR The parent was convicted as an adult or as a delinquent by a court of competent jurisdiction of sexual assault resulting in the conception of a child EXCEPT for a violation of C.G.S. §53a-71 or C.G.S. §53a-73a.

THE PETITIONER FURTHER REPRESENTS that no person is under legal disability or in the military service of the United States or allied nation, except as indicated above (Title 50 Appendix U.S.C. 520) and that there is a no proceeding pending or contemplated in another court affecting the custody of said minor child to the best knowledge and belief of the petitioner. C.G.S. §52-231a. [If such a proceeding is pending or contemplated, give full details on Second Sheet, PC-180.] THE PETITIONER FURTHER REPRESENTS that all of the information contained herein is true to the best of his or her knowledge and belief. IF THE WHEREABOUTS OF THE PARENT(S) OR PUTATIVE FATHER ARE UNKNOWN, the petitioner makes affidavit that a diligent search has been made for the missing parent(s) or putative father as set forth below: [If more space is needed, use Second Sheet, PC-180.]

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RECORDED(CONFIDENTIAL VOLUME): APPLICATION/ STATE OF CONNECTICUT TERMINATION OF PARENTAL RIGHTS COURT OF PROBATE PC-600 REV. 10/00 Page 3 [For the legal effects of a Termination of Parental Rights Decree, see below.]

WHEREFORE, THE PETITIONER REQUESTS that this Court terminate the parental rights of ,and PETITIONS the Court to: appoint a statutory parent for said minor child, adoption being contemplated. [A copy of any consent to adoption previously executed by a parent to an authorized agency shall accompany this application.] appoint a guardian of the person of said minor child. affirm that the remaining parent shall be the sole parent and natural guardian of the minor child. Proposed statutory parent or guardian of the person: The representations contained herein are made under the penalties of false statement. ............................................................................................................. Guardian Ad Litem: Date: .......................................................................................... Petitioner: Date: [Any signature by a minor or incompetent petitioner must be approved by a guardian ad litem. C.G.S. §45a-715.] PROPOSED STATUTORY PARENT/GUARDIAN OF THE PERSON IF APPOINTED, I WILL ACCEPT SAID POSITION OF TRUST. Signature ......................................................................................... Name [Type or print. Include maiden name, if applicable.] Address and zip code Telephone number: DATE OF BIRTH:

CONSENT TO TERMINATION I do consent to termination of my parental rights. [Any consent for an incompetent or minor parent must be signed by a guardian ad litem. C.G.S. §45a-708. Any consent to termination of parental rights must be accompanied by an Affidavit of Consent to Termination of Parental Rights, JD-JM-60. C.G.S. §45a-715. To waive personal service, form PC-633, Waiver of Personal Service Parental Rights Matters, must be filed.] DATE DULY ACKNOWLEDGED BEFORE ME ............................................................................................. Father: ............................................................................................. Mother: ............................................................................................. Guardian Ad Litem: ............................................................................................. Judge, Ass't Clerk, Notary Public, Comm. Sup.Ct. ................................................................................................ Judge, Ass't Clerk, Notary Public, Comm. Sup.Ct. ........................................................................................... Judge, Ass't Clerk, Notary Public, Comm. Sup.Ct.

JOINDER AND CONSENT OF MINOR CHILD I, the minor child, having attained the age of twelve years, do join in this application for termination of parental rights. C.G.S. §45a-715. [This statement applies in all cases where a minor is twelve years of age or older. Only complete the statement below if a statutory parent will be appointed.] I, the minor child, having attained the age of twelve years, of Children and Families. consent do not consent to being photo-listed with the Department ........................................................................................ Minor Child:

LEGAL EFFECTS OF A TERMINATION OF PARENTAL RIGHTS DECREE Termination of parental rights means "the 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." C.G.S. §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 child. The parent will have no legal right to care for the child or make any decisions on behalf of the child. - the legal right to the child's birth certificate. - the legal right to any state and federal benefits the parent may have been receiving for the child. - the legal responsibility to support the child and to pay for the child's maintenance, medical, and other expenses, but the parent MAY be responsible for support of the child until the effective date of the termination. - the legal responsibility to care for the child or make any decisions on his or her behalf. FURTHERMORE, upon a decree of termination, the 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. APPLICATION/TERMINATION OF PARENTAL RIGHTS PC-600 Page 3 of 3
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IN ORDER FOR THE PETITION TO BE GRANTED, THE COURT MUST MAKE FINDINGS IN REGARD TO: (1) The timeliness, nature, and extent of services offered, provided, and made available to the parent and the child by an agency to facilitate the reunion of the child with the parent. (2) The terms of any applicable court order entered into and agreed upon by any individual or agency and the parent and the extent to which all parties have fulfilled their obligations under such order. (3) The feelings and emotional ties of the child with respect to his parents, any guardian of his person, and any person who has exercised physical care, custody, or control of the child for at least one year and with whom the child has developed significant emotional ties. (4) The age of the child. (5) The efforts the parent has made to adjust his circumstances, conduct, or conditions to make it in the best interest of the child to return him to his home in the foreseeable future, including, but not limited to, (A) the extent to which the parent has maintained contact with the child as part of an effort to reunite the child with the parent, provided the Court may give weight to incidental visitations, communications, or contributions and (B) the maintenance of regular contact or communication with the guardian or other custodian of the child. (6) The extent to which a parent has been prevented from maintaining a meaningful relationship with the child by the unreasonable act or conduct of the other parent of the child, or the unreasonable act of any other person, or by the economic circumstances of the parent.

APPLICATION / TERMINATION OF PARENTAL RIGHTS PC - 600, Page 2 (Reverse) REV. 10/ 00