AFFIDAVIT/CONSENT TO TERMINATION OF PARENTAL RIGHTS
JD-JM-60 Rev. 8-06 C.G.S. §§ 17a-112, 45a-707, 45a-715
STATE OF CONNECTICUT
COURT OF PROBATE
COURT USE ONLY DOCKET NO.
1. 2. 3. 4.
INSTRUCTIONS Print or type; this form must be filed with every consent termination. Attach original to Superior Court form JD-JM-40 or Probate Court form PC-600 or PC-601. This affidavit may not be executed by a mother within 48 hours immediately after the birth of her child. If a minor parent is consenting to the termination of parental rights, a Guardian Ad Litem appointed by the court shall assure that such minor parent is giving an informed and voluntary consent.
ADDRESS OF SUPERIOR COURT
SUPERIOR COURT AT COURT OF PROBATE
FOR PROBATE DISTRICT OF PROBATE DISTRICT NO. OR JUVENILE VENUE NO. DATE AND T ME OF BIRTH OF CHILD/YOUTH
NAME OF PARENT WHO IS CONSENTING TO TERMINATION OF PARENTAL RIGHTS
In the matter of
I, THE PARENT NAMED ABOVE, voluntarily and knowingly consent to the termination of my parental rights. Termination means "the complete severance by court order of the legal relationship, with all its rights and responsibilities, between the child and the child's 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." Gen. Stat. § 45a-707 (Inheritance rights cease upon adoption.) I understand that no action taken with respect to my consent to termination of my parental rights affects the parental rights of the other parent. I UNDERSTAND the termination of my parental rights to mean that I will NO LONGER have the following legal rights and responsibilities upon the effective date of termination: 1. the legal right to custody, guardianship or control of the child/youth; I will have no legal right to care for the child/youth or make any decisions on behalf of thechild/youth; 2. the legal right to obtain the child's/youth's birth certificate; 3. the legal right to any state or federal benefits I may have been receiving for the child/youth; 4. the legal responsibility to support the child/youth and to pay for the child's/youth's maintenance, medical and other expenses, but I MAY be responsible for support of the child/youth until the effective date of the termination; 5. the responsibility to care for the child/youth or make any decisions on his/her behalf.
, a person under the age of eighteen.
I HAVE CONSIDERED THE FOLLOWING: 1. the child/youth will be legally free for adoption following the termination and I will have no right to notice of the adoption proceedings nor any right to participate in the proceedings; 2. as an alternative to the termination of my parental rights, the nature and extent of family and counseling services which may be available through an agency which could improve the relationship between the child/youth and me or reunite the child with me; 3. the child's/youth's feelings and the emotional ties of the child/youth toward me; 4. the extent to which I may have been prevented from maintaining a meaningful relationship with the child/youth by actions of the other parent of the child/youth or any other person, or by my economic circumstances. 5. My consent today may permit the Department of Children and Families to seek to terminate my parental rights to another child of mine under the age of seven. It may seek to do so without giving me more than ninety (90) days to rehabilitate, if such child has been found neglected by the court. I am aware that the court must conduct a hearing before approving the termination of parental rights even if both parents consent to the termination. I am aware that the child/youth, upon reaching his/her 18th birthday, may have the right to information which may identify me or other blood relatives.
IF PARENT IS A MINOR, SIGNATURE OF GUARDIAN AD LITEM
This is to certify that the above document was signed in my presence after having been read by the subscriber, who stated that she (he) understood its contents. This is to certify that the above document was signed in my presence after it was read by me to the subscriber in the language understood by her (him) and that she (he) further stated that she (he) understood the contents of this consent and authorization for adoption.
SUBSCRIBED AND SWORN TO BEFORE ME ON (Date) AT (Town) SIGNED (Judge, Asst. Clerk, Notary Pub., Comm. of Sup. Court)