Free PC-504 - Connecticut

APPLICATION/APPOINTMENT OF TEMPORARY GUARDIAN PC-504 REV. 10/04

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

RECORDED(CONFIDENTIAL VOLUME):

TO: COURT OF PROBATE, DISTRICT OF IN THE MATTER OF Presently residing at

DISTRICT NO. A MINOR CHILD BORN ON The minor child is the subject of a pre-existing child support order.

PROPOSED TEMPORARY GUARDIAN [Name, address, zip PETITIONER [Name, address, zip code, telephone number, social security number, and legal status of petitioner (e. g. parent, guardian of code, social security number, and birth date. ] the person) C.G.S §45a-622.]

PERSONS WHO HAVE GUARDIANSHIP RIGHTS WITH RESPECT TO SAID MINOR CHILD [If any is a minor, give date of birth; if incompetent or in military service, so indicate. Give last known address and zip code. C.G.S. §45a-621. Also give social security number, if known.] MOTHER

FATHER [Including an unwed father, C.G.S. §45a-604. If father is unknown, so state.]

GUARDIAN(S) OF THE PERSON OF THE MINOR

Explain why the parent(s) or guardian(s) is/are unable to care for the minor. [E.g., absence from jurisdiction, illness, etc.]

THE PETITIONER 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.] WHEREFORE THE PETITIONER REQUESTS that this Court appoint a temporary guardian of the person of said minor to commence on 20 the date of the Court decree and to terminate one year from the date of said decree OR In no event shall such guardianship exceed the period of one year. The representations contained herein are made under the penalties of false statement.

..................................................................................... Petitioner: Date: Date:

................................................................................ Petitioner:

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

Signature(s) ....................................................................................................................................................................... Name(s) [Type or print.] Address(es) and zip code(s)

Telephone Number(s): APPLICATION/APPOINTMENT OF TEMPORARY GUARDIAN PC-504 RESET