JD-FM-221 Rev. 1-20 (Page 1 of 2) (Continued on Page 2)
Connecticut is the home state of the child(ren) at the time of the filing of this case.
The child(ren) has or have lived in Connecticut for the past 6 months, or from birth if the child(ren) is or are younger
than 6 months old.
The child(ren) lived in Connecticut for at least 6 months but was or were taken from Connecticut less than 6 months
ago by a person claiming custody, and a parent or guardian continues to live here.
The child(ren) and at least 1 parent have a significant connection to Connecticut and there is substantial evidence in
Connecticut concerning the child(ren)'s present or future care, protection, training and personal relationships.
The child(ren) is or are in Connecticut now and has or have been abandoned or there is an emergency affecting the
No other state has an interest in hearing this case and it is in the best interest of the child(ren) for a Connecticut
court to hear the case.
4. Connecticut has the authority to decide this case and should decide this case because: (Select all that apply)
VERIFIED PETITION FOR VISITATION -
GRANDPARENTS & THIRD PARTIES
JD-FM-221 Rev. 1-20
C.G.S. §§ 46b-56, 46b-59; P.B. §§ 25-4, 25-5
1. I am the child(ren)'s:
3. I want visitation rights with the child(ren) listed below:
Child's name (First, middle, last)
Date of birth
2. The respondent(s) is/are the:
Attach Order to Attend Hearing (JD-FM-162), and Affidavit Concerning Children (JD-FM-164).
If you are a parent of the child or children, use the Custody/Visitation Application - Parent (JD-FM-161).
(Attach additional sheets if necessary)
Name(s) of parent(s) or guardian(s) (First, middle initial, last)
Judicial District of
Petitioner's name (Last, first, middle initial) Respondent's name (Last, first, middle initial)
Additional respondent's name (If applicable)
Mother Father Grandparent Other:
COURT USE ONLY
STATE OF CONNECTICUT
For information on ADA accommodations,
contact a court clerk or go to: www.jud.ct.gov/ADA.