Free APPEAL FROM ORDER ISSUED IN - Connecticut

APPEAL FROM ORDER ISSUED IN STATE OF CONNECTICUT RECORDED (CONFIDENTIAL VOLUME) RESPONSE TO PUBLIC HEALTH EMERGENCY: ISOLATION/QUARANTINE/ COURT OF PROBATE VACCINATION [Type or print in black ink.] CM-68 REV. 5/06

TO: COURT OF PROBATE, DISTRICT OF IN THE MATTER OF (Name, address where confined/isolated and zip code)

DISTRICT NO. PETITIONER (Name, address, zip code, and tel. number)

Hereinafter referred to as the respondent. The undersigned petitioner represents that: a public health emergency has been declared by the Governor under C.G.S. §19a-131a OR a public health emergency has been declared by the local health director under C.G.S. §19a-221, AND the respondent: has been isolated OR has been quarantined (C.G.S. §19a-131b or C.G.S. §19a-221) OR is subject to an order of vaccination under C.G.S. §19a-131e within the jurisdiction of this Court and hereby requests a hearing to appeal such order, which is dated: __________________________________________. WHEREFORE, the petitioner RESPECTFULLY REQUESTS THE COURT to hold a hearing to:

Modify such order with the following terms:

Release Respondent from such order.

Dated at

Connecticut this

day of

, 20

.

The representations contained herein are made under the penalties of false statement.

____________________________________ Petitioner's Signature

APPEAL FROM ORDER ISSUED IN RESPONSE TO PUBLIC HEALTH EMERGENCY: ISOLATION/QUARANTINE/VACCINATION CM-68 RESET