Fillable PC 510 (State of Connecticut, Office of the Probate Court Administrator)

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PC 510 (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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CONNECTICUT PROBATE COURTS
Custodian’s Affidavit/
Immediate Temporary Custody
PC-510 REV. 10/17
CONFIDENTIAL
Custodian’s Affidavit /Immediate Temporary Custody PC-510
RECEIVED:
Instructions
1)
The person who has actual physical custody of a minor child must complete this form to be submitted with a
petition for immediate temporary custody.
2) For more information, see C.G.S. section 45a-607 (b) (1).
3) Type or print the form in ink. Use an additional sheet, or Second Sheet, PC-180, if more space is needed.
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
Person with physical custody of the child (Name, address and telephone number.)
Hereinafter referred to as the custodian.
The custodian represents that:
1) The minor child has been in his/her custody since:
2) The custodian obtained custody of the minor child under the following circumstances:
3) Immediate temporary custody of the minor child is necessary, and determination of the need for temporary
custody cannot await notice of hearing because of the following facts: (Be specific.)
The representations made in this affidavit are made under the penalty of false statement.
Signature of Custodian
Type or Print Name
Date
RESET
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PC 510 (State of Connecticut, Office of the Probate Court Administrator)

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Completed 20 July 2020

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