Fillable *PETVIS* VERIFIED PETITION FOR VISITATION - GRANDPARENTS & (State of Connecticut/Department of Administrative Services)

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*PETVIS* VERIFIED PETITION FOR VISITATION - GRANDPARENTS & (State of Connecticut/Department of Administrative Services)

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JD-FM-221 Rev. 1-20 (Page 1 of 2) (Continued on Page 2)
a.
b.
c.
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
child(ren)'s well-being.
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:
Instructions:
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)
d.
e.
f.
Docket number
Judicial District of
At (Town)
Petitioner's name (Last, first, middle initial) Respondent's name (Last, first, middle initial)
Additional respondent's name (If applicable)
Grandparent
Other: (Specify)
Mother Father Grandparent Other:
*PETVIS*
PETVIS
COURT USE ONLY
STATE OF CONNECTICUT
SUPERIOR COURT
www.jud.ct.gov
For information on ADA accommodations,
contact a court clerk or go to: www.jud.ct.gov/ADA.
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JD-FM-221 Rev. 1-20 (Page 2 of 2)
Claim for Relief
Signature of Petitioner
Print name of person signing at left Date signed
Address
Telephone (Area code first)
Visitation as follows:
Verification
I declare under penalty of perjury that this Petition for Visitation is true and correct.
Upon motion, the court may order the payment of fees for another party, the attorney for the minor child, the guardian ad
litem, or any expert by any party in accordance with such party's financial ability.
Signed (Petitioner)
Subscribed and
sworn to before me:
Signed (Clerk, Notary, Commissioner of Superior Court
Date signed
The Petitioner asks the Court for:
5.
I have a relationship with the child(ren) that is parent-like. (Explain in detail how your relationship is parent-like):
6.
Denial of visitation will cause real and significant harm to the child(ren).
(Explain in detail what harm would be caused to the child(ren) by a denial of visitation):
Important Note:
Your answers to questions 5 and 6 will determine whether you are eligible to make your request for visitation.
If you need more space, add additional sheets.
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*PETVIS* VERIFIED PETITION FOR VISITATION - GRANDPARENTS & (State of ConnecticutDepartment of Administrative Services)

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Completed 3 September 2021

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