TO: COURT OF PROBATE, DISTRICT NO.

RECORDED(CONFIDENTIAL VOLUME):APPLICATION/REMOVAL OF GUARDIAN PC-500 REV. 7/12 Page 1 of 3

IN THE MATTER OF [Name, address where residing, zip code, and telephone number.]

PETITIONER [Name, address, zip code, telephone number, and legal status of petitioner (e. g. adult relative, counsel for minor, courton its own motion). C.G.S. § 45a-614. If adult relative, also give date of birth. If counsel for minor, also list juris number.]

TO BE REMOVED AS GUARDIAN [Name(s), address(es), zip code(s), telephone number(s), and Indian tribe and

OTHER PERSON(S) WITH GUARDIANSHIP RIGHTS [Name(s), address(es), zip code(s), telephone number(s) and Indian

THE PETITIONER ALLEGES that the whereabouts of the respondent(s) are unknown. The last-known address(es) of therespondent(s) is/are:

THE PETITIONER STATES that the following efforts have been made to obtain a current address for the respondent(s):[To be completed only if the above box is checked.]

APPLICATION/REMOVAL OF GUARDIANPC-500 Page 1 of 3

MINOR CHILD'S BIRTH DATE

TRIBE AND RESERVATION of minor child, if an Indian child as defined by P.L. 95-608, 25 U.S.C. 1901, et seq. [Name and address]

RELATIONSHIP TO MINOR CHILD

STATE OF CONNECTICUT

COURT OF PROBATE

Hereinafter referred to as the minor child.

RELATIONSHIP TO MINOR CHILD

PERSON(S)reservation, if a member as defined by P.L. 95-608, 25 U.S.C. 1901, et seq. If parent, also give date of birth.]

Hereinafter referred to as the respondent(s)

tribe and reservation, if a member as defined by P.L. 95-608, 25 U.S.C. 1901, et seq. ]

Complete Confidential Information Sheet for PC-500 on last page. Use Second Sheet, PC-180, for additional data.][Type or print in black ink. File in duplicate.]

The minor child has been abandoned by the parent or guardian in the sense that the parent or guardian has failed to maintain areasonable degree of interest, concern, or responsibility for the child's welfare.

The minor child has been denied the care, guidance, or control necessary for physical, educational, moral, or emotional well-beingas a result of acts of parental commission or omission, as defined by law.

The minor child has had physical injury or injuries inflicted upon him or her, other than by accidental means, as defined by law.

THE PETITIONER REPRESENTS that the minor child presently resides in the town written above, was born on the date written above,that the persons who have guardianship rights are stated above, and that the respondent(s) named above should be removed as guardian(s)of the person of the minor child for the following reason(s) as provided by law. C.G.S. §§ 45a-613 and 45a-610.

The respondent(s) consent(s) to removal as guardian(s) of the minor child. [No further allegation against a consenting guardian isnecessary.]

The minor child has been neglected or uncared for, as defined in C.G.S. § 46b-120.

APPLICATION/REMOVAL OF GUARDIANPC-500 REV. 7/12 Page 2 of 3

RECORDED(CONFIDENTIAL VOLUME):STATE OF CONNECTICUT

COURT OF PROBATE[Type or print in black ink . File in duplicate.]

THE PETITIONER FURTHER REPRESENTS that to the best of his or her knowledge and belief:

The following respondent(s) is/are under a legal disability:

There is a no proceeding pending or contemplated in Connecticut or any other state affecting the custody of the minor child. C.G.S. §§ 52-231a and 46b-115 et seq. [Complete and attach form JD-FM-164, Affidavit Concerning Children.]

The minor child is is not the subject of a pre-existing child support order.

There is is not a current protective order or restraining order involving any party. If so, please attach.

There is is not a current safety or service agreement between the Department of Children and Families and the parent/guardian of the minor child.

The minor child has has not resided in Connecticut continuously for the last six months. C.G.S. § 46b-115 et seq.

APPLICATION/REMOVAL OF GUARDIANPC-500 Page 2 of 3

WHEREFORE THE PETITIONER REQUESTS that this court remove the respondent(s) as guardian(s) of the person of said minor child

Affirm

The representations contained herein are made under the penalties of false statement.

Date: ........................................................................Petitioner:

The following respondent(s) is/are in the military service of the United States or Allied Nation (Title 50 Appendix, U.S.C. 520).

There has been has not been a proceeding in the past in Connecticut or any other state affecting the custody of the minor child.C.G.S. § 52-231a and 46b-115 et seq.

No respondent(s) is under a legal disability.

No respondent(s) is in the military service.

and PETITIONS the court to:

Appoint a guardian(s) of the person of said minor child.

is the sole guardian.Name

PROPOSED GUARDIAN(S)IF APPOINTED, I WILL ACCEPT THE POSITION OF TRUST.

Signature .......................................................................................................................................................................

Name [Type or print. Include maiden name, if applicable.]

Address and zip code:

DATE DULY ACKNOWLEDGED BEFORE ME

............................................................... .....................................................................................

.............................................................. .....................................................................................

.............................................................. .......................................................................................

Parent's/Guardian's Signature

Parent's/Guardian's Signature

Parent's/Guardian's Signature

Judge, Ass't Clerk, Notary Public, Comm. Sup. Ct.

Judge, Ass't Clerk, Notary Public, Comm. Sup. Ct.

Judge, Ass't Clerk, Notary Public, Comm. Sup. Ct.

APPLICATION/REMOVAL OF GUARDIANPC-500 Page 3 of 3

Minor's Signature

DATE DULY ACKNOWLEDGED BEFORE ME

............................................................... .....................................................................................Judge, Ass't Clerk, Notary Public, Comm. Sup. Ct.

Telephone Number: Date of Birth:

Type Name:

Type Name:

Type Name:

Type Name:

STATE OF CONNECTICUT

COURT OF PROBATE

[Type or print in black ink . File in duplicate.]

APPLICATION/REMOVAL OF GUARDIANPC-500 REV. 7/12 Page 3 of 3

CONSENT OF MINOR CHILD

I, the undersigned minor, being at least twelve years of age, hereby consent to the appointment of the proposed guardian as my guardian. C.G.S. § 45a-617.

I do consent to the removal of my guardianship rights with respect to said minor child. [Any consent for an incompetent or minor parent must be approved by a guardian ad litem. C.G.S. § 45a-621. To waive personal service, form PC-633, Waiver of Personal Service Parental Rights Matters, must be filed.]

CONSENT TO REMOVAL OF GUARDIANSHIP

Signature .......................................................................................................................................................................

Name [Type or print. Include maiden name, if applicable.]

Address and zip code:

Telephone Number: Date of Birth:

IF APPOINTED, I WILL ACCEPT THE POSITION OF TRUST.

CONFIDENTIAL STATE OF CONNECTICUT DO NOT RECORD INFORMATION SHEET FOR PC-500, Application/ COURT OF PROBATERemoval of Guardian [Type or Print in Black Ink.] NEW 7/12 _____________________________________________________________________________________

Court of Probate, ______________________________________________ District

In the Matter of ______________________________________________________, a minor child.

The social security numbers of the following persons are required in connection with this proceeding.

1) Petitioner who is an adult relative of the minor child:

Name: __________________________________________________________________

Social Security Number:____________________________________________________

2) Person(s) to be removed as guardian(s):

a. Name: ___________________________________________________________________

Social Security Number: ____________________________________________________

b. Name: ___________________________________________________________________

Social Security Number: ____________________________________________________

3) Proposed guardian(s):

a. Name: ___________________________________________________________________

Social Security Number: ____________________________________________________

b. Name: ___________________________________________________________________

Social Security Number: ____________________________________________________