Application For Emergency Ex Parte Order Of Custody {JD-FM-222}

APPLICATION FOR EMERGENCY EX PARTE ORDER OF CUSTODY JD-FM-222 Rev. 9-14 C.G.S. Sec. 46b-56f(c); P.A. 14-207, Sec. 9 STATE OF CONNECTICUT 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. Court Use Only SUPERIOR COURT www.jud.ct.gov Instructions 1. Complete this form including the affidavit on page 2. 2. Attach an Affidavit Concerning Children form JD-FM-164. 3. If there is not yet a court case, or post-judgment motion to modify custody, you must file it with this application (e.g., the divorce, legal separation, annulment, custody action, or post-judgment motion to modify custody must be filed with this application). Judicial District of At (Town) 4. Bring the original and a copy of this form to the court clerk's office. 5. After your application is processed, the clerk will give you the proper papers to have served on the respondent. 6. Make sure the originals are returned to court after service. Return date (If applicable) Docket number EXPCUS *EXPCUS* Name of case (Plaintiff v. Defendant) 1. I, (Name and address) am the Applicant for this emergency ex parte order of custody, and I am the Child's Name (First, Middle Initial, Last) , Mother Father Legal Guardian of the following child or children for whom I am seeking this order (attach additional sheets if necessary): Date of birth (Month, day, year) 2. The Respondent (Name and address) is the Mother Father Legal Guardian of the child or children named above. 3. I am filing or there is already a pending matter in which I am a party for: divorce (dissolution of marriage). annulment. post-judgment modification of custody. 4. I believe there is an immediate and present risk of physical danger or psychological harm to the child or children named above as further explained in the attached affidavit. legal separation. custody of the child or children named above. I ask the Court to enter the following ex parte orders: Temporary custody to Visitation as follows: No visitation. Respondent may not remove the child or children from the State of Connecticut. Respondent may not interfere with Applicant's custody of the child or children. Respondent may not interfere with the educational program of the child or children. Other (specify): . . Signed (Attorney or self-represented party) Address (Number, street, town or city, state, zip code) Printed name of person signing Date signed Telephone number ( (Page 1 of 3) ) - American LegalNet, Inc. www.FormsWorkFlow.com Name of Case (Plaintiff v. Defendant) Docket number Affidavit I, (Name) , am the Applicant in this matter and swear to the following (explain the events that have occurred, when they occurred, and why you believe that there is an immediate and present risk of physical danger or psychological harm to the child or children): 1. An emergency ex parte order is required because (attach additional sheets if necessary): 2. An emergency ex parte order is in the best interests of the child or children because there is an immediate and present risk of physical danger or psychological harm to the child or children named in this application. have have not been a party or a witness or participated in any other capacity in cases in 3. (Check one) I Connecticut or in any other state concerning custody or any child listed in this application. If you have, identify the name of any court(s), the court case number(s) and the date(s) of any order(s): 4. (Check one) I have or another person has taken the following actions to inform the respondent of this application (if it was another person, state who it is): No actions have been taken to inform the respondent of this application, but the court should consider this application on an ex parte basis for the following reasons: I certify that the statements above are true to the best of my knowledge and belief Signed (Affiant) Print name of person signing Subscribed and sworn to before me (Assistant Clerk, Commissioner of Superior Court, Notary Public) Date signed JD-FM-222 Rev. 9-14 (Page 2 of 3) American LegalNet, Inc. www.FormsWorkFlow.com Name of Case (Plaintiff v. Defendant) Docket number Order The Court has reviewed this application and finds that an immediate and present risk of physical danger or psychological harm to the child or children exists, and in the best interests of the child or children the Court enters the following ex parte order: Temporary custody to Visitation as follows: No visitation. Respondent may not remove the child or children named in the application from the State of Connecticut. Respondent may not interfere with Applicant's custody of the child or children named in the application. Respondent may not interfere with the educational program of the child or children named in the application. Other: This application for ex parte orders is denied. By the Court (Judge) Date ordered Order for Hearing and Summons (To be completed by clerk) The court orders that a hearing be held at the time and place shown below, which, if relief on the application is ordered ex parte, shall not be later than 14 days from the date of such order for hearing. The court further orders notice to be given by the Applicant to the Respondent of the Application, Affidavit, any ex parte order if issued, and the time and place of the hearing, by having a true and attested copy served on the Respondent by any proper officer at least 5 days before the date of the hearing. Proof of service must be made to this Court. Superior Court, Judicial District of Date Hearing to be held at Court address Room number Time To any proper officer: By the Authority of the State of Connecticut, you must serve a true and attested copy of the Application, Affidavit, Ex Parte Order if any, and Order for Hearing and Summons on the person named below in one of the ways required by law at least 5 days before the date of the hearing, and file proof of service with this Court. Person to be served Address By the Court Assistant Clerk Date signed JD-FM-222 Rev. 9-14 (Page 3 of 3) American LegalNet, Inc. www.FormsWorkFlow.com