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Fillable Printable Connecticut Affidavit of Birth Form

Fillable Printable Connecticut Affidavit of Birth Form

Connecticut Affidavit of Birth Form

Connecticut Affidavit of Birth Form

TO:
COURT
OF
PROBATE,
DISTRICT
NO.
RECORDED
(CONFIDENTIAL
PLACE
OF
BIRTH
OF
MINOR
CHILD
DATE
OF
BIRTH
OF
MINOR
CHILD
IN
THE
INTEREST
OF
[
Name,
present
address,
zip
code,
sex
]
a
person
under
18
years
of
age,
hereinafter
referred
to
as
the
minor
child.
Jurisdiction
based
on:
Petitioner or minor child resides in the probate district.
PETITIONER
[
Name,
address,
zip
code,
telephone
number,
the
nature
of
the
relationship
to
minor
child
and
legal
status
of
petitioner.
C.G.S.
§45a-715.
]
FATHER:
[
Include
putative
father
named
by
the
mother.
]
The
petitioner
represents
that
the
whereabouts
of
the
parent(s)
or
putative
father
are
unknown.
[
If
this
box
is
checked,
complete
affidavit
section
at
bottom
of
Page
3.
]
IF
PARENT(S)
TO
BE
TERMINATED
IS
A
MINOR,
LIST
THE
PARENT
OR
GUARDIAN
OF
THE
MINOR
PARENT.
[
Name(s),
address(es),
zip
code(s),
telephone
number(s),
and
relationship
]
STATE OF CONNECTICUT
COURT OF PROBATE
PARENT(S) OF MINOR CHILD [Name(s),address(es), and Indian tribe and reservation, if a member as defined by P.L. 95-608,
25 U.S.C.1901, et. seq.]
MOTHER:
APPLICATION/TERMINATION OF PARENTAL RIGHTS
PC-600 Page 1 of 5
Continued
[Type or print in black ink. Indicate if any information is unknown.Attach: 1) certified copy of birth
certificate and 2) statement of facts under oath relating to grounds for termination. (See page 2.)
Complete Confidential Information Sheet for PC-600 on last page. File this form in duplicate.]
APPLICATION/TERMINATION OF
PARENTAL RIGHTS
PC-600 REV. 7/12 Page 1
Minor child is under the guardianship of a duly-licensed child care or child-placing agency, which has an
office in the probate district.
The minor child is presently or was formerly the recipient of state assistance.
Party whose parental rights are to be terminated is under a
court order to pay child support.
TRIBE AND RESERVATION of minor child, if an Indian child as defined by P.L. 95-608, 25 U.S.C. 1901, et seq. [Name and address]
FATHER'S DATE OF BIRTH
MOTHER'S DATE OF BIRTH
.
GUARDIAN OF PERSON OF MINOR CHILD, if other than parent, and GUARDIAN AD LITEM APPOINTED IN PRIOR
PROCEEDING(S), if any. [
Name(s), address(es), zip code(s), and telephone number(s)]
AGENCY THAT PLACED THE CHILD IN CURRENT PLACEMENT. [Name, address, and zip code]
APPLICATION/
TERMINATION OF
PARENTAL RIGHTS
PC-600
REV. 7/12 Page 2
RECORDED (CONFIDENTIAL VOLUME):
THE PETITIONER REPRESENTS that the MINOR CHILD presently resides in the town named above, was born on the date written above,
and the persons who may have parental rights are as stated above, AND THAT the parental rights of the person(s) indicated below should be
terminated for the following reasons, as provided by statute.
Attached hereto and made a part hereof is a statement of facts made under oath relating to each ground for termination.
C.G.S. § 45a-717. See notice below.
THE PETITIONER REPRESENTS that the termination of the parental rights of
is in the best interests of the child, AND THAT
OR
consent(s) to termination of their parental rights with respect to
the minor child.
[No further allegation is necessary against a consenting parent. However, an Affidavit of Consent to Termination
of Parental Rights, JD-JM-60, and a statement of facts related to this ground for termination must accompany this application.]
APPLICATION/TERMINATION OF PARENTAL RIGHTS
PC-600 Page 2 of 5
Continued
NOTICE -- IN ORDER TO GRANT THE PETITION, THE COURT MUST MAKE FINDINGS IN REGARD TO:
(1) The timeliness, nature, and extent of services offered, provided, and made available to the parent and the child by
an agency to facilitate the reunion of the child with the parent.
(2) The terms of any applicable court order entered into and agreed upon by any individual or agency and the parent and the
extent to which all parties have fulfilled their obligations under such order.
(3) The feelings and emotional ties of the child with respect to his parents, any guardian of his person, and any person who
has exercised physical care, custody, or control of the child for at least one year and with whom the child has developed significant
emotional ties.
(4) The age of the child.
(5) The efforts the parent has made to adjust his circumstances, conduct, or conditions to make it in the best interest of the
child to return him to his home in the foreseeable future, including, but not limited to, (A) the extent to which the parent has main-
tained contact with the child as part of an effort to reunite the child with the parent, provided the court may give weight to incidental
visitations, communications, or contributions and (B) the maintenance of regular contact or communication with the guardian or other
custodian of the child.
(6) The extent to which a parent has been prevented from maintaining a meaningful relationship with the child by the
unreasonable act or conduct of the other parent of the child, or the unreasonable act of any other person, or by the economic
circumstances of the parent.
STATE OF CONNECTICUT
COURT OF PROBATE
[For the legal effects of a Termination of Parental Rights Decree, see page 5.]
RECORDED
(CONFIDENTIAL
APPLICATION/
TERMINATION
OF
PARENTAL
RIGHTS
PC-600
REV.
7/12
Page
3
STATE
OF
CONNECTICUT
COURT OF PROBATE
[
For
legal
effects
of
a
Termination
of
Parental
Rights
Decree,
see
page
5.
]
OR
OR
The
child
has
been
found
in
a
prior
proceeding
by
the
Probate
Court
for
the
District
of
or
the
Superior
Court
for
the
Judicial
District
of
to
have
been
neglected
or
uncared
for,
AND
the
parent
has
failed
to
achieve
such
degree
of
personal
rehabilitation
as
would
encourage
the
belief
that,
within
a
reasonable
time
and
considering
the
age
and
needs
of
the
child,
such
parent
could
assume
a
responsible
position
in
the
life
of
the
child.
The
parent
has
killed
through
deliberate,
nonaccidental
act,
another
child
of
the
parent
OR
has
requested,
commanded,
importuned,
attempted,
conspired,
or
solicited
such
killing
OR
has
committed
an
assault
through
deliberate
and
nonaccidental
act
that
has
re-
sulted
in
serious
bodily
injury
to
another
child
of
the
parent.
IF
THE
WHEREABOUTS
OF
THE
PARENT(S)
OR
PUTATIVE
FATHER
ARE
UNKNOWN,
the
petitioner
makes
affidavit
that
a
diligent
search
has
been
made
for
the
missing
parent(s)
or
putative
father
as
set
forth
below:
[
If
more
space
is
needed,
use
Second
Sheet,
PC-180.
]
OR
OR
The
child
is
under
seven
years
of
age
AND
is
neglected
or
uncared
for,
AND
the
parent
of
the
child
has
failed,
is
unable,
or
is
unwilling
to
achieve
such
degree
of
personal
rehabilitation
as
would
encourage
the
belief
that,
within
a
reasonable
amount
of
time,
considering
the
age
and
needs
of
the
child,
such
parent
could
assume
a
responsible
position
in
the
life
of
the
child,
AND
such
parent's
parental
rights
of
another
child
were
previously
terminated
pursuant
to
a
petition
filed
by
the
Commissioner
of
Children
and
Families.
The
parent
was
convicted
as
an
adult
or
as
a
delinquent
by
a
court
of
competent
jurisdiction
of
sexual
assault
resulting
in
the
conception
of
a
child
EXCEPT
for
a
violation
of
C.G.S.
§ 53a-71
or
C.G.S.
§ 53a-73a.
The child is found to be neglected or uncared for AND has been in the custody of the Commissioner of the Department of Children
and Families for at least fifteen months, AND the parent has been provided specific steps to take to facilitate the return of the child
to the parent pursuant to C.G.S. § 46b-129, as amended, AND the parent has failed to achieve such degree of personal rehabilitation
as would encourage the belief that, within a reasonable time and considering the age and needs of the child, such parent could assume
a responsible position in the life of the child.
The child has been abandoned by in the sense that the
parent has failed to maintain a reasonable degree of interest, concern, or responsibility as to the welfare of the child.
OR
There has been sexual molestation and exploitation, severe physical abuse, or a pattern of abuse.
The child has been denied the care, guidance, or control necessary for the child's physical, educational, moral, or emotional
well-being, by reason of acts of parental commission or omission by
There has been a nonaccidental or inadequately explained serious physical injury to the child.
There is no ongoing parent/child relationship as defined in C.G.S. § 45a-717(g), and to allow further time for the establishment or
reestablishment of the parent/child relationship would be detrimental to the best interests of the child.
OR
OR
APPLICATION/TERMINATION OF PARENTAL RIGHTS
PC-600 Page 3 of 5
VOLUME):
APPLICATION/
TERMINATION
OF
PARENTAL
RIGHTS
PC-600
REV.
7/12
Page
4
[
For
the
legal
effects
of
a
Termination
of
Parental
Rights
Decree,
see Page 5.]
and
PETITIONS
the
court
to:
,
affirm
that
the
remaining
parent
shall
be
the
sole
parent
and
natural
guardian
of
the
minor
child.
Proposed
statutory
parent
or
guardian
of
the
person:
appoint
a
statutory
parent
for
the
minor
child,
adoption
being
contemplated.
[
A
copy
of
any
consent
to
adoption
previously
executed
by
a
parent
to
an
authorized
agency
shall
accompany
this
application.
]
WHEREFORE,
THE
PETITIONER
REQUESTS
that
this
court
terminate
the
parental
rights
of
[Any
signature
by
a
minor
or
incompetent
petitioner
must
be
approved
by
a
guardian
ad
litem.
C.G.S.
§ 45a-715.]
Date:
Date:
RECORDED(CONFIDENTIAL
..........................................................................................
.............................................................................................................
Guardian Ad Litem:
Petitioner:
THE PETITIONER FURTHER REPRESENTS that all of the information contained herein is true to the best of his or her knowledge and
belief.
APPLICATION/TERMINATION OF PARENTAL RIGHTS
PC-600 Page 4 of 5
STATE OF CONNECTICUT
COURT OF PROBATE
THE PETITIONER FURTHER REPRESENTS that to the best of his or her knowledge and belief:
The following respondent(s) is/are under a legal disability:
There is a no proceeding pending or contemplated in Connecticut or any other state affecting the custody of the minor child.
C.G.S. §§ 52-231a and 46b-115 et seq. [Complete and attach form JD-FM-164, Affidavit Concerning Children.]
The minor child isis not the subject of a pre-existing child support order.
There is is not a current protective order or restraining order involving any party. If so, please attach.
There isis not a current safety or service agreement between the Department of Children and Families and the parent/guardian of
the minor child.
The minor child has has not resided in Connecticut continuously for the last six months. C.G.S. § 46b-115 et seq.
There has beenhas not been a proceeding in the past in Connecticut or any other state affecting the custody of the minor child.
C.G.S. § 52-231a and 46b-115 et seq.
No respondent(s) is under a legal disability.
No respondent(s) is in the military service.
The following respondent(s) is/are in the military service of the United States or Allied Nation (Title 50 Appendix, U.S. C.520).
The representations contained herein are made under the penalties of false statement.
appoint a guardian(s) of the person of the minor child.
IF APPOINTED, I WILL ACCEPT THE POSITION OF TRUST.
Signature
Name [
Type or print. Include maiden name, if applicable.]
Address and zip code:
Telephone number:
DATE OF BIRTH:
.........................................................................................
PROPOSED STATUTORY PARENT/GUARDIAN(S) OF THE PERSON
APPLICATION/TERMINATION OF PARENTAL RIGHTS
PC-600 Page 5 of 5
LEGAL EFFECTS OF A TERMINATION OF PARENTAL RIGHTS DECREE
Termination of parental rights means "the complete severance by court order of the legal relationship, with all of its rights and
responsibilities between the child and his parent or parents so that the child is free for adoption except it shall not affect the right of
inheritance of the child or the religious affiliation of the child." C.G.S. § 45a-707(8).(Inheritance rights cease upon adoption.) No action
taken with respect to the termination of parental rights of one parent affects the parental rights of the other parent.
Upon a decree of termination of parental rights, the parent will NO LONGER have the following rights and responsibilities with
respect to the minor child who is the subject of the decree:
-- the legal right to custody, guardianship, or control of the child. The parent will have no legal right to care for the child or to
make any decisions on behalf of the child
-- the legal right to the child's birth certificate
-- the legal right to any state and federal benefits the parent may have been receiving for the child
-- the legal responsibility to support the child and to pay for the child's maintenance, medical and other expenses, but the
parent MAY be responsible for support of the child until the effective date of the termination
-- the legal responsibility to care for the child or make any decisions on his or her behalf
FURTHERMORE, upon a decree of termination, the child will be legally free for adoption, and the parent will have no right to notice of the
adoption proceedings nor any right to participate in the proceedings.
................................................................................................
Judge, Ass't Clerk, Notary Public, Comm. Sup.Ct.
CONSENT TO TERMINATION
I do consent to termination of my parental rights.
Any consent for an incompetent or minor parent must be signed by a guardian ad litem.
C.G.S. § 45a-708. Any consent to termination of parental rights must be accompanied by an Affidavit of Consent to Termination of
Parental Rights, JD-JM-60. C.G.S. § 45a-715. To waive personal service, form PC-633, Waiver of Personal Service Parental Rights
Matters, must be filed.
]
DATE
DULY ACKNOWLEDGED BEFORE ME
Judge, Ass't Clerk, Notary Public, Comm. Sup.Ct.
.............................................................................................
...........................................................................................
Judge, Ass't Clerk, Notary Public, Comm. Sup.Ct.
JOINDER AND CONSENT OF MINOR CHILD
I, the minor child, having attained the age of twelve years, do join in this application for termination of parental rights. C.G.S. § 45a-715.
[This statement applies in all cases where a minor is twelve years of age or older. Only complete the statement below if a statutory parent
will be appointed.]
........................................................................................
I, the minor child, having attained the age of twelve years,
consent
do not consent to being photo-listed with the Department
of Children and Families.
.............................................................................................
.............................................................................................
.............................................................................................
Father:
Mother:
Guardian Ad Litem:
Minor Child:
IF APPOINTED, I WILL ACCEPT THE POSITION OF TRUST.
Signature
Name [
Type or print. Include maiden name, if applicable.
]
Address and zip code:
Telephone number:
DATE OF BIRTH:
.........................................................................................
VOLUME):
APPLICATION/
TERMINATION OF
PARENTAL RIGHTS
PC-600 REV. 7/12 Page 5
STATE OF CONNECTICUT
COURT OF PROBATE
[
For the legal effects of a Termination of Parental Rights Decree, see below.
]
RECORDED(CONFIDENTIAL
CONFIDENTIAL
STATE
OF
CONNECTICUT
DO NOT RECORD
INFORMATION SHEET
FOR PC-600, Application/
COURT
OF
PROBATE
Termination of Parental Rights
[
Type or Print in Black Ink.
]
NEW 7/12
_____________________________________________________________________________________
Court of Probate,
In the Matter of
,a minor child.
1) Mother:
Name:
Social Security Number:
2) Father:
Name:
Social Security Number:
The social security numbers of the parent(s) of the minor child are required in connection with this
proceeding
3) Proposed Guardian(s):
a. Name:
Social Security Number:
b. Name:
Social Security Number:
,District.
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