Free PC-702 - Connecticut

APPLICATION/STERILIZATION OF ADULT PC-702 REV. 10/00

STATE OF CONNECTICUT
RECORDED(CONFIDENTIAL VOLUME):

COURT OF PROBATE [Type or print in black ink.] DISTRICT NO.
RESPONDENT'S DATE OF BIRTH

TO: COURT OF PROBATE, DISTRICT OF IN THE MATTER OF

Hereinafter referred to as the respondent. PRESENT ADDRESS OF RESPONDENT

LEGAL STATUS OF PETITIONER (C.G.S. §45a-692) Person Seeking Sterilization (Respondent) Respondent's Physician Guardian of Respondent (C.G.S. §45a--677(e)(3)

RESPONDENT'S TOWN OF DOMICILE

Director of Institution Conservator of Respondent (C.G.S. Ch. 802h) Interested Party [Explain interest.]

PETITIONER [Name, address, and zip code]

CONSERVATOR OR GUARDIAN OF RESPONDENT [Name, address, and zip code]

PERSONS TO WHOM NOTICE SHOULD BE GIVEN: RESPONDENT, SPOUSE [If any], PARENTS [If any], SIBLINGS [If no parents], DIRECTOR OF THE INSTITUTION WHERE THE RESPONDENT CURRENTLY RESIDES, ATTORNEY FOR RESPONDENT, OFFICE OF PROTECTION AND ADVOCACY, OTHER INTERESTED PERSONS [Give names, addresses, and zip codes. If attorney for respondent, list juris number.] C.G.S. §45a-693.

Additional data [on Second Sheet, PC-180] ,if any, is made a part hereof. The petitioner states the following reasons for seeking such determination: (C.G.S. §45a-692)

THE PETITIONER REPRESENTS that said respondent: Is now living at the present address written above and is domiciled in the town written above and has attained the age of eighteen years. THE PETITIONER FURTHER REPRESENTS that sterilization is in the best interests of the respondent because of the following factors: Less drastic alternative contraceptive methods have proved unworkable or inapplicable in the respondent's case. The respondent is physiologically sexually mature. There is no evidence of infertility. The respondent has the capability and a reasonable opportunity for sexual activity. The respondent is unable to understand reproduction or contraception and there exists the likely permanence of that inability. The respondent's physical or emotional inability to care for the child. The proponents of the sterilization are seeking sterilization in good faith, and their primary concern is for the best interests of the respondent rather than their own convenience or the convenience of the public. In the case of females, procreation would endanger the life or severely impair the health of the individual. WHEREFORE, THE PETITIONER REQUESTS THAT: This Court determine the respondent's ability to give informed consent, the respondent not being under conservatorship or guardianship. If the Court determines the respondent is not able to give informed consent, that the Court retain jurisdiction and determine whether or not sterilization is in the best interests of the respondent. The respondent being under conservatorship or guardianship, the Court determine whether or not sterilization is in the best interests of the respondent. The representations contained herein are made under the penalties of false statement.

Date: APPLICATION/STERILIZATION OF ADULT PC-702

............................................................................ Petitioner: RESET