In the matter of
To
1. Print or type; this form must be filed with every consent termination.
2. Attach original to Superior Court form JD-JM-40 or Probate Court
form PC-600 or PC-601.
3. This affidavit may not be executed by a mother within 48 hours
immediately after the birth of her child.
4. If a minor parent is consenting to the termination of parental rights, a
Guardian Ad Litem appointed by the court shall assure that the minor
parent is giving an informed and voluntary consent.
AFFIDAVIT/CONSENT TO TERMINATION
OF PARENTAL RIGHTS
JD-JM-60 Rev. 7-11
C.G.S. §§ 17a-112, 45a-707, 45a-715;
PA 11-240, Sec. 2
STATE OF CONNECTICUT
SUPERIOR COURT
COURT OF PROBATE
www.jud.ct.gov
Court use only
Instructions
, a person under the age of eighteen.
I, the parent named above, voluntarily and knowingly consent to the
termination of my parental rights. Termination means "the complete
severance by court order of the legal relationship, with all its rights
and responsibilities, between the child and the child's parent or
parents so that the child is free for adoption except it shall not affect
the right of inheritance of the child or the religious affiliation of the
child." Section 45a-707 of the Connecticut General Statutes
(Inheritance rights cease upon adoption.) I understand that no
action taken with respect to my consent to termination of my
parental rights affects the parental rights of the other parent.
I understand the termination of my parental rights to mean that I will
no longer have the following legal rights and responsibilities on the
effective date of termination:
1. the legal right to custody, guardianship or control of the child or
youth; I will have no legal right to care for the child or youth or
make any decisions on behalf of the child or youth;
2. the legal right to obtain the child's or youth's birth certificate;
3. the legal right to any state or federal benefits I may have been
receiving for the child or youth;
4. the legal responsibility to support the child or youth and to pay for
the child's or youth's maintenance, medical and other expenses,
but I may be responsible for support of the child or youth until the
effective date of the termination;
5. the responsibility to care for the child or youth or make any
decisions on his or her behalf.
Signed (Judge, Assistant Clerk, Notary Public, Comm. of Sup. Court)
Signed (Parent)
If parent is a minor, signature of guardian ad litem
This is to certify that the above document was signed in my presence after it was read by me to the subscriber in the
language understood by her (him) and that she (he) further stated that she (he) understood the contents of this consent and
authorization for adoption.
I have considered the following:
1. the child or youth will be legally free for adoption after the
termination and I will have no right to notice of the adoption
proceedings nor any right to participate in the proceedings;
2. as an alternative to the termination of my parental rights, the
nature and extent of family and counseling services which may be
available through an agency which could improve the relationship
between the child or youth and me or reunite the child or youth
with me;
3. the child's or youth's feelings and the emotional ties of the child or
youth toward me;
4. the extent to which I may have been prevented from maintaining a
meaningful relationship with the child or youth by actions of the
other parent of the child or youth or any other person, or by my
economic circumstances.
5. My consent today in the Superior Court for Juvenile Matters
may permit the Department of Children and Families to seek to
terminate my parental rights to another child of mine under the
age of seven. It may seek to do so without giving me more than
ninety (90) days to rehabilitate, if the child has been found
neglected, uncared for or abused by the court.
I am aware that the court must conduct a hearing before approving
the termination of parental rights even if both parents consent to the
termination.
I am aware that the child or youth, upon reaching his or her 18th
birthday, may have the right to information which may identify me or
other blood relatives.
This is to certify that the above document was signed in my presence after having been read by the subscriber, who
stated that she (he) understood its contents.
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.
Docket number
Superior Court
Court of Probate
Address of Superior Court
For Probate District of Probate district number or juvenile venue number
Name of parent who is consenting to termination of parental rights Date and time of birth of child/youth
Subscribed and sworn to before me on (Date) At (Town)
