Fillable PC 502 (State of Connecticut, Office of the Probate Court Administrator)

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PC 502 (State of Connecticut, Office of the Probate Court Administrator)

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BROWSE STATE OF CONNECTICUT, OFFICE OF THE PROBATE COURT ADMINISTRATOR (CT) FORMS

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CONN
ECTICUT PROBATE COURTS
Petition/Temporary Custody
PC-502 REV. 10/19
CONFIDENTIAL
Petition/Temporary Custody PC-502 Page 1 of 4
RECEIVED:
Instructions:
1)
An adult relative may use this form to petition for the appointment of a temporary custodian of a minor child
if a petition for: a) removal of a guardian, b) termination of parental rights, or c) appointment of a guardian of
a minor child who has no guardian has been filed with the court.This form may also be used by an attorney for
a minor child or by an adult who is not a relative, but who has actual physical
custody of the minor child at the
time the petition is filed.
2)
The petition should be filed in the court for the probate district in which the minor child resides, is domiciled
or is located at the time
of filing the petition. If the petitioner is requesting temporary custody pending termination
of parental rights, the petition may also be filed where the petitioner resides.
3)
A birth certificate (long-form) and JD-FM-164, Affidavit Concerning Children, should be filed with the
petition. Also file Confidential Sheet, PC-502CI, with confidential social security numbers.
4)
For more information, see C.G.S. sections 45a-607, 45a-603 et seq., 45a-706 et seq., 46b-115 et seq. and 52-231a.
5)
Type or print in ink. Use an additional sheet, or PC-180, if more space is needed
a.
Relationship to minor child:
b. If parent, date of birth:
c. In
military service of US or Allied Nation: Yes No
d.
Indian tribe and reservation:
e. Legally incompetent: Yes
No
a.
Relationship to minor child:
b.
If parent, date of birth:
c.
In military service of US or Allied Nation: Yes No
d.
Indian tribe and reservation:
e. Legally incompetent:
Yes No
Hereinafter referred to as the respondent(s)
Probate Court Name
District Number
In the Matter of (Name of minor child) (Hereinafter referred to as the minor child)
Minor Child’s Date of Birth
Persons to be Removed as Guardian/Parental Rights Terminated. (For each person, list name, address, telephone
number; relationship to the child; date of birth if a parent; whether in the military service of the United States or an Allied
Nation (50 U.S.C. section 3931); Indian tribe and reservation, if a member as defined by 25 U.S.C. section 1903; and whether
the person is legally incompetent.)
Petitioner (Name, address and telephone
number)
Petitioner is:
Adult relative (List relationship and date of birth.)
Attorney for minor child (Attach Appearance of Attorney, PC-183.)
Adult with actual physical custody of minor child. (List date of birth, and describe
circumstances under which the minor came to be in the petitioner’s custody):
Tribe and Reservation of Minor Child, if an Indian Child as defined by 25 U.S.C. section 1903 (Name and address)
Address where minor child resides
Addre
ss where
minor
child
is
domiciled
(if different)
Address where minor child is located at
time of filing petition(if different)
6)
Contact the court regarding payment of service of process fees and, if applicable, payment of newspaper notice
publication.
RESET
Petition/Temporary Custody
PC-502 REV. 10/19
CONFIDENTIAL
Petition/Temporary Custody
PC-502 Page 2 of 4
If a parent listed above is a minor or legally incompetent, list the parents or guardian/conservator for the parent
(Include the name, address, telephone number and relationship.)
1. 2.
Name of parent whose parental rights were previously terminated, if any
Name of deceased parents or guardians, if any
The petitioner alleges that the whereabouts of the respondents are unknown.
The last-known address of the respondents is:
The following efforts have been made to obtain the current address for the respondents:
Other persons with guardianship rights. (For each person, list name, address, telephone number; relationship to the
child; date of birth if a parent; whether parent is in the military service of the United States or an Allied Nation; Indian tribe
and reservation, if a member as defined by 25 U.S.C. section 1903; and whether the person is legally incompetent.)
Parents whose guardianship rights have previously been removed by a court. (For each person, list name, address,
telephone number; relationship to the child; date of birth; whether the parent is in military service of the United States or an
Allied Nation; Indian tribe and reservation, if a member as defined by 25 U.S.C. section 1903; and whether the person is
legally incompetent.)
Minor child is in the current physical care of: (Name, address and telephone number. State relationship to minor child.)
CONN
EC
TI
C
UT
PROBATE COURTS
CONNECTICUT PROBATE COURTS
Petition/Temporary Custody
PC-502 REV. 10/19
CONFIDENTIAL
Petition/Temporary Custody PC-502 Page 3 of 4
The petitioner represents that:
A petition i
s pending in this court for the removal of one or both parents as guardians or for the removal of the
guardian of the minor child; OR
A petition is pending in this court for the termination of parental rights with respect to the minor child; OR
The petitioner has reasonable grounds to believe that the minor child has no guardian of his or her person, and a
petition for the appointment of a guardian is pending.
The parents or other guardians consent to an order of temporary custody of the minor child. [No further allegation
is necessary against a consenting parent/guardian.]
The petitioner
further represents that the parent or other guardian has performed acts of omission or commission as set
forth in C.G.S. sections 45a-610:
The minor child has been abandoned by the parent or guardian in the sense that the parent or guardian has failed
to maintain a reasonable degree of interest, concern or responsibility for the child’s welfare.
The minor child has been denied the care, guidance or control necessary for physical, educational, moral or
emotional well-being as defined by law.
The minor child has had physical injuries inflicted upon him or her by a person responsible for such child’s health,
welfare, or care, or by a person given access to such child by such responsible person, other than by accidental
means, or has injuries which are at variance with the history given of them or is in a condition which is the result of
maltreatment such as, but not limited to, malnutrition, sexual molestation, deprivation of necessities, emotional
maltreatment or cruel punishment.
The minor child has been neglected or uncared for, as defined in C.G.S. section 46b-120.
AND BECAUSE OF SUCH ACTS, THE CHILD IS SUFFERING FROM SERIOUS PHYSICAL ILLNESS, SERIOUS
PHYSICAL INJURY, OR THE IMMEDIATE THREAT THEREOF, OR IS IN IMMEDIATE PHYSICAL DANGER.
The petitioner alleges the following specific acts of omission or commission (with dates, times and places),
which cause the child to suffer serious physical illness or serious physical injury, or the immediate threat thereof, or
place him or her in immediate physical danger.
The petitioner further represents that to the best of his or her knowledge and belief:
The minor child has resided has not resided in Connecticut continuously for the last six months.
There is a proceeding is not a proceeding pending or contemplated in Connecticut or any other state affecting
the custody of the minor child.
There has been a proceeding has not been a proceeding in the past in Connecticut or any other state
affecting the custody of the minor child.
There is is not a current safety or service agreement between the Department of Children and Families
and the parent/guardian of the minor child.
There is is not a current protective order or restraining order involving any party. If so, please attach.
The minor child is is not the subject of a pre-existing child support order.
Petition/Temporary Custody
PC-502 REV. 10/19
CONFIDENTIAL
Petition/Temporary Custody PC-502 Page 4 of 4
The petitioner further represents that it is in the best interest of the minor child that temporary custody of the minor child
be granted to a proper person as provided in C.G.S. section 45a-607, pending determination of the:
removal of parent as guardian matter
termination of parental rights matter, or
petition for appointment of a guardian for the minor child, who has no guardian.
WHEREFORE the petitioner requests that an order for temporary custody for the minor child be granted to:
_________________________________________________________ [List name and relationship to minor child.]
The representations made in this petition are made under penalty of false statement.
Signature of
Petitioner
Type or Print Name
Date
Acceptance of Trust of Temporary Custodian(s)
If appointed, I will accept the position of trust:
Signature of Proposed
Temporary Custodian
Type or Print Name
(Include all prior names.)
Date
Address
Phone Number
Date of Birth
Signature of Proposed
Temporary Custodian
Type or Print Name
(Include all prior names.)
Date
Address
Phone Number
Date of Birth
Consent to Temporary Custody
I consent to an order of temporary custody of the minor child. [A parent may waive personal service by filing a
Waiver of Personal or Abode Service/Parental Rights Matter, PC-633.]
Signature of Par
ent/Guardian Duly Acknowledged Before Me
Type or Print Name
Date Judge, Clerk, Public Notary, Comm. Sup. Ct.
Signature of Parent/Guardian Duly Acknowledged Before Me
Type or Print Name
Date Judge, Clerk, Public Notary, Comm. Sup. Ct.
CONN
ECTICUT PROBATE COURTS
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PC 502 (State of Connecticut, Office of the Probate Court Administrator)

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Completed 21 July 2020

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