Free PC-905 - Connecticut

APPLICATION/ EMANCIPATION OF MINOR PC-905 REV. 3/03

STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink.]

RECORDED(CONFIDENTIAL VOLUME):

TO: COURT OF PROBATE, DISTRICT OF NAME,ADDRESS, and TELEPHONE NUMBER OF MINOR SEX

DISTRICT NO.
DATE OF BIRTH

AGE
SOCIAL SECURITY NO.

NAMES OF PARENTS OR LEGAL GUARDIANS OR OTHER INTERESTED PERSONS Name [Please also list Social Security No.] Relationship to Minor Residence[Street, Town, and Zip Code] Tel. Number

PETITIONER:

Minor

Parent/Guardian

RESPONDENT

Minor

Parent/Guardian

Jurisdiction is based on the residence of either the minor or his parents or guardian in this probate district. WHEREFORE, the petitioner requests that the court declare that the above-named minor be emancipated on the following statutory grounds: (1) The minor has entered into a valid marriage whether or not that marriage has been terminated by dissolution; or (2) The minor is on active duty with any of the armed forces of the United States of America; or (3) The minor willingly lives separate and apart from his or her parents or guardian, with or without the consent of the parents or guardian, and the minor is managing his or her own financial affairs, regardless of the source of any lawful income; or (4) For good cause shown, it is in the best interests of the minor, any child of the minor, or the parents or guardian of the minor. STATE FACTS/REASONS FOR EMANCIPATION [Use additional sheets if necessary.]

The representations contained herein are made under the penalties of false statement. Date: APPLICATION/EMANCIPATION OF MINOR PC-905 ......................................................................... Petitioner:

RESET