Fillable Connecticut APPLICATION FOR EMERGENCY EX PARTE ORDER OF CUSTODY

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Connecticut APPLICATION FOR EMERGENCY EX PARTE ORDER OF CUSTODY

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(Page 1 of 3)
APPLICATION FOR EMERGENCY
EX PARTE ORDER OF CUSTODY
JD-FM-222 Rev. 9-14
C.G.S. Sec. 46b-56f(c); P.A. 14-207, Sec. 9
STATE OF CONNECTICUT
SUPERIOR COURT
www.jud.ct.gov
Instructions
1. Complete this form including the affidavit on page 2.
2. Attach an Affidavit Concerning Children form JD-FM-164.
3. If there is not yet a court case, or post-judgment motion to modify
custody, you must file it with this application (e.g., the divorce,
legal separation, annulment, custody action, or post-judgment
motion to modify custody must be filed with this application).
4. Bring the original and a copy of this form to the court
clerk's office.
5. After your application is processed, the clerk will give you
the proper papers to have served on the respondent.
6. Make sure the originals are returned to court after service.
Court Use Only
EXPCUS
*EXPCUS*
Judicial District of
At (Town) Return date (If applicable)
Docket number
Name of case (Plaintiff v. Defendant)
ADA NOTICE
The Judicial Branch of the State of Connecticut complies
with the Americans with Disabilities Act (ADA). If you
need a reasonable accommodation in accordance with
the ADA, contact a court clerk or an ADA contact person
listed at www.jud.ct.gov/ADA.
1. I, (Name and address)
,
am the Applicant for this emergency ex parte order of custody, and I am the
Mother Father Legal Guardian
of the following child or children for whom I am seeking this order (attach additional sheets if necessary):
Child's Name (First, Middle Initial, Last) Date of birth (Month, day, year)
2. The Respondent (Name and address)
is the
Mother Father Legal Guardian of the child or children named above.
3. I am filing or there is already a pending matter in which I am a party for:
divorce (dissolution of marriage).
legal separation.
annulment. custody of the child or children named above.
post-judgment modification of custody.
4. I believe there is an immediate and present risk of physical danger or psychological harm to the child or children named
above as further explained in the attached affidavit.
I ask the Court to enter the following ex parte orders:
Temporary custody to
.
Visitation as follows:
.
No visitation.
Respondent may not remove the child or children from the State of Connecticut.
Respondent may not interfere with Applicant's custody of the child or children.
Respondent may not interfere with the educational program of the child or children.
Other (specify):
Signed (Attorney or self-represented party)
Printed name of person signing Date signed
Address (Number, street, town or city, state, zip code)
Telephone number
(
)
-
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(Page 2 of 3)
JD-FM-222 Rev. 9-14
Name of Case (Plaintiff v. Defendant)
Docket number
Affidavit
I, (Name) , am the Applicant in this matter and swear to the following (explain
the events that have occurred, when they occurred, and why you believe that there is an immediate and present risk of
physical danger or psychological harm to the child or children):
1. An emergency ex parte order is required because (attach additional sheets if necessary):
2. An emergency ex parte order is in the best interests of the child or children because there is an immediate and present
risk of physical danger or psychological harm to the child or children named in this application.
3. (Check one) I
have have not been a party or a witness or participated in any other capacity in cases in
Connecticut or in any other state concerning custody or any child listed in this application. If you have, identify the name
of any court(s), the court case number(s) and the date(s) of any order(s):
4. (Check one)
I have or another person has taken the following actions to inform the respondent of this application (if it was another
person, state who it is):
No actions have been taken to inform the respondent of this application, but the court should consider this application
on an ex parte basis for the following reasons:
I certify that the statements above are true
to the best of my knowledge and belief
Signed (Affiant)
Print name of person signing
Subscribed and sworn to before me (Assistant Clerk, Commissioner of Superior Court, Notary Public)
Date signed
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(Page 3 of 3)
JD-FM-222 Rev. 9-14
Name of Case (Plaintiff v. Defendant)
Docket number
Order
The Court has reviewed this application and finds that an immediate and present risk of physical danger or
psychological harm to the child or children exists, and in the best interests of the child or children the Court
enters the following ex parte order:
This application for ex parte orders is denied.
Temporary custody to
Visitation as follows:
No visitation.
Respondent may not interfere with Applicant's custody of the child or children named in the application.
Respondent may not interfere with the educational program of the child or children named in the application.
Other:
Respondent may not remove the child or children named in the application from the State of Connecticut.
By the Court (Judge)
Date ordered
Order for Hearing and Summons (To be completed by clerk)
The court orders that a hearing be held at the time and place shown below, which, if relief on the application is ordered ex
parte, shall not be later than 14 days from the date of such order for hearing. The court further orders notice to be given by
the Applicant to the Respondent of the Application, Affidavit, any ex parte order if issued, and the time and place of the
hearing, by having a true and attested copy served on the Respondent by any proper officer at least 5 days before the date
of the hearing. Proof of service must be made to this Court.
Hearing to
be held at
q
Superior Court, Judicial District of
Court address
Date
Room number Time
To any proper officer: By the Authority of the State of Connecticut, you must serve a true and attested copy of the Application,
Affidavit, Ex Parte Order if any, and Order for Hearing and Summons on the person named below in one of the ways required
by law at least 5 days before the date of the hearing, and file proof of service with this Court.
Person to be served Address
By the Court Assistant Clerk Date signed
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Connecticut APPLICATION FOR EMERGENCY EX PARTE ORDER OF CUSTODY

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Completed 12 April 2020

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