Free PC-501 - Connecticut

APPLICATION/IMMEDIATE TEMPORARY CUSTODY PC-501 REV. 10/04 Page 1

STATE OF CONNECTICUT
RECORDED(CONFIDENTIAL VOLUME):

COURT OF PROBATE [Type or print in black ink. File in duplicate.] DISTRICT NO. MINOR CHILD'S BIRTH DATE

TO: COURT OF PROBATE, DISTRICT OF IN THE MATTER OF [Name, address where residing, and zip code.]

Hereinafter referred to as the minor child. PETITIONER [Name, address, zip code, telephone number, and legal status of petitioner (e. g. adult relative, counsel for minor). If adult relative, also give social security number and date of birth. If counsel for minor, also list juris number.]

The minor child is the subject of a pre-existing child support order.

PARENT(S)/GUARDIAN(S) [Name(s), address(es), zip code(s), and telephone number(s). Indicate parent/guardian to be removed/ terminated. If parent, state social security number and date of birth.]

MINOR CHILD IS PRESENTLY IN THE CUSTODY OF:[Name, address, zip code, and telephone number. State 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 PETITIONER FURTHER REPRESENTS that: The minor child is in the custody of a person other than the parent or other guardian, [If this box is checked, Custodian's Affidavit, PC-510, must be filed with this application. ] AND The child was not taken or kept from the parent(s) or guardian(s), AND there is a substantial likelihood that the child will be removed from this jurisdiction prior to a hearing for temporary custody; OR To return the child to the parent(s) or guardian(s) would place the child in circumstances that would result in serious physical illness or injury, or the threat thereof, or imminent physical danger prior to a hearing for temporary custody; OR The minor child is hospitalized as a result of serious physical illness or serious physical injury and is in need of immediate medical or surgical treatment, the delay of which would be life-threatening, AND the parent(s) or guardian(s) refuses to consent or is unable to consent to such treatment. [If this box is checked, certificates from two physicians, PC-550, must be filed with this application.] OR The minor child is in the custody of the parent(s) or guardian(s), AND the minor child has suffered from serious physical illness or serious physical injury and is in need of immediate medical or surgical treatment, the delay of which would be life-threatening, AND the parent(s) or guardian(s) refuses to consent or is unable to consent to such treatment. THE PETITIONER FURTHER REPRESENTS that: The minor child has been abandoned by the parent or other guardian in the sense that the parent or other guardian has failed to maintain a reasonable degree of interest, concern, or responsibility for the minor's welfare; OR The minor child has been denied the care, guidance, or control necessary for physical, educational, moral, or emotional well-being as a result of acts of parental commission or omission, as defined by law. C.G.S. §45a-610.

AND THESE ACTS PLACE THE HEALTH OR WELFARE OF THE MINOR CHILD IN DANGER. Continued APPLICATION/IMMEDIATE TEMPORARY CUSTODY PC-501 Page 1 of 2

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APPLICATION IMMEDIATE TEMPORARY CUSTODY PC-501 REV. 12/00 Page 2

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. that place the health or welfare of the minor child in danger. Included are dates, times, and places.

[To give further details, use Second Sheet, PC-180.] THE PETITIONER FURTHER REPRESENTS 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 proceeding is pending or contemplated, give full details using Second Sheet, PC-180.] THE PETITIONER FURTHER REPRESENTS that it is in the best interest of said minor child that immediate temporary custody of said minor child be granted to a proper person as provided in C.G.S. §45a-607, pending the determination of the aforesaid matter. WHEREFORE THE PETITIONER REQUESTS that an order for immediate temporary custody for said 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:

[If petitioner is requesting a waiver of fees, attach PC-184, Request/Order Waiver of Fees - Petitioner.] PROPOSED TEMPORARY CUSTODIAN IF APPOINTED, I WILL ACCEPT SAID POSITION OF TRUST.

Signature ......................................................................................................................................................................... Name [Type or print.] Address and zip code

Telephone Number: APPLICATION/IMMEDIATE TEMPORARY CUSTODY PC-501 Page 2 of 2

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