Free PC-602 - Connecticut

APPLICATION/APPOINTMENT OF STATUTORY PARENT/TERMINATION PC-602 REV. 3/03

STATE OF CONNECTICUT
RECORDED (CONFIDENTIAL VOLUME):

COURT OF PROBATE [Type or print in black ink. File in duplicate.] [Use when parental rights have been terminated.] DISTRICT NO. DATE AND PLACE OF BIRTH OF CHILD PRESENTLY RESIDES AT MINOR CHILD

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

A MINOR CHILD Jurisdiction based on Petitioner or minor child resides in probate district. The main or local office of the petitioner or proposed statutory parent is located in this probate district. GUARDIAN OF MINOR CHILD [Name, address, zip code, and telephone number]

PROPOSED STATUTORY PARENT OF MINOR CHILD: Commissioner of Children and Families Child-Placing Agency[Name, main or local address, and telephone number] PETITIONER:

The PETITIONER REPRESENTS that: The guardian named above, if any, has guardianship of the minor child. Adoption is contemplated for the minor child, and appointment of a statutory parent is required. The minor child is free for adoption for the following reasons: C.G.S. §45a-725. The minor child has no living parents. [File Adoption Data Sheet, PC-680, together with certified copy of birth certificate of minor child as Exhibits A and B with Application .] The parental rights of all persons having such rights have been terminated. [File Adoption Data Sheet, PC-680, together with certified copy of birth certificate of minor child as Exhibits A and B with Application. ] The minor child is from outside the United States, its territories, or the Commonwealth of Puerto Rico, and has no living parents OR the rights of all parties in connection with the minor child have been properly terminated under the laws of the jurisdiction in which the minor child was domiciled prior to being removed to Connecticut. [File an Affidavit with Application giving complete details, together with copies of pertinent documents, e.g., Birth Record or Extract of Family Register, Appointment of Guardian, Consent to Adoption and Emigration, Adoption Agreement between foreign adoption agency and/or guardian and child-placing agency, etc.] The PETITIONER FURTHER REPRESENTS that: no proceeding pending or contemplated in another court affecting the custody of said minor child, to the best There is a knowledge and belief of the petitioner. C.G.S. §52-231a. [If such proceeding is pending or contemplated, give full details. Use Second Sheet, PC-180. ] The data herein provided and the exhibits submitted with this application are true and complete to the best knowledge and belief of the petitioner. WHEREFORE, THE PETITIONER REQUESTS that this Court terminate the guardianship of the guardian named above, if any, and appoint the proposed statutory parent named above as the statutory parent of the minor child. The representations contained herein are made under the penalties of false statement.

Date:

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

THE PROPOSED STATUTORY PARENT, IF APPOINTED, WILL ACCEPT THE RESPONSIBILITY SIGNED................................................................................................... by its

APPLICATION/APPOINTMENT OF STATUTORY PARENT/TERMINATION PC-602 RESET