Adoption Petition {JD-JM-195}

ADOPTION PETITION JD-JM-195 New 10-12 P.A. 12-82, Sec. 16 C.G.S. § 45a-724 STATE OF CONNECTICUT SUPERIOR COURT JUVENILE MATTERS www.jud.ct.gov Instructions Attach: JD-JM-196, Adoption Data Sheet, JD-JM-197, Adoption Agreement, and Adoption Social Study. Address of Court Docket number Name of minor child Date of birth Petitioner address (Statutory parent - Department of Children and Families) Phone number Name and address of adopting parent Phone number Name and address of adopting parent Phone number The Petitioner Department of Children and Families represents that: 1. The Superior Court for Juvenile Matters listed above granted a petition to terminate parental rights and appointed the Department of Children and Families the statutory parent on (date) . 2. Any appeal or appeal period of the Termination of Parental Rights Order has expired. 3. The Adoption Data Sheet, Adoption Social Study and Adoption Agreement attached to this petition are a part of this petition and the information and data in those documents are true and complete to the best knowledge and belief of the petitioner. 4. The minor child is free for adoption. 5. To the best knowledge and belief of the petitioner there is is not a proceeding in Connecticut or any other state now or in the past that could affect the custody of the minor child. (Complete and attach JD-JM-30, Custody Affidavit.) The Petitioner asks that this court: Approve the Adoption Agreement submitted with this petition between the petitioner and the adopting parent(s). Change the name of the minor child to: The representations contained in this petition are made under penalties of false statement by a duly authorized representative of the Department of Children and Families. Signed (Petitioner) Subscribed and sworn to before me on (Date) Date Signed (Judge, Assistant Clerk, Notary, Comm. Superior Court) Consent of Minor Child I am 12 years old or older and consent to this petition. Signed (Minor child) Date signed ADA NOTICE 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. American LegalNet, Inc. www.FormsWorkFlow.com