Print Form

STATE OF CONNECTICUT

APPLICATION/REMOVAL OF
RECORDED(CONFIDENTIAL VOLUME):
GUARDIAN
COURT OF PROBATE
PC-500 REV. 7/12 Page 1 of 3
[Type or print in black ink. File in duplicate.]
Complete Confidential Information Sheet for PC-500 on last page. Use Second Sheet, PC-180, for additional data.]
TO: COURT OF PROBATE,

DISTRICT NO.

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

MINOR CHILD'S BIRTH DATE

Hereinafter referred to as the minor child.

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]

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

PERSON(S) TO BE REMOVED AS GUARDIAN [Name(s), address(es), zip code(s), telephone number(s), and Indian tribe and
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.]
RELATIONSHIP TO
MINOR CHILD

Hereinafter referred to as the respondent(s)

OTHER PERSON(S) WITH GUARDIANSHIP RIGHTS [Name(s), address(es), zip code(s), telephone number(s) and Indian
tribe and reservation, if a member as defined by P.L. 95-608, 25 U.S.C. 1901, et seq. ]
RELATIONSHIP TO
MINOR CHILD

THE PETITIONER ALLEGES that the whereabouts of the respondent(s) are unknown. The last-known address(es) of the
respondent(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 GUARDIAN
PC-500
Page 1 of 3

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

STATE OF CONNECTICUT

RECORDED(CONFIDENTIAL VOLUME):

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

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 is
necessary.]
The minor child has been abandoned by the parent or guardian in the sense that the parent or guardian has failed to maintain a
reasonable 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-being
as 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 minor child has been neglected or uncared for, as defined in C.G.S. 46b-120.
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:
No respondent(s) is under a legal disability.
The following respondent(s) is/are in the military service of the United States or Allied Nation (Title 50 Appendix, U.S.C. 520).
No respondent(s) is in the military service.
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.]
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.
The minor child

is

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

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.
There

is

The minor child

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

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

WHEREFORE THE PETITIONER REQUESTS that this court remove the respondent(s) as guardian(s) of the person of said minor child
and PETITIONS the court to:
Appoint a guardian(s) of the person of said minor child.
Affirm

is the sole guardian.

Name

The representations contained herein are made under the penalties of false statement.
Date:
APPLICATION/REMOVAL OF GUARDIAN
PC-500
Page 2 of 3

........................................................................
Petitioner:

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

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

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 of Birth:

Telephone Number:
IF APPOINTED, I WILL ACCEPT THE POSITION OF TRUST.

Signature .......................................................................................................................................................................
Name [Type or print. Include maiden name, if applicable.]
Address and zip code:

Date of Birth:

Telephone Number:

CONSENT TO REMOVAL OF GUARDIANSHIP

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.]
DATE
...............................................................
Parent's/Guardian's Signature

DULY ACKNOWLEDGED BEFORE ME

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

Type Name:
..............................................................
Parent's/Guardian's Signature

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

Type Name:
..............................................................
Parent's/Guardian's Signature

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

Type Name:
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.
DATE

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

...............................................................
Minor's Signature
Type Name:
APPLICATION/REMOVAL OF GUARDIAN
PC-500
Page 3 of 3

DULY ACKNOWLEDGED BEFORE ME

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CONFIDENTIAL
STATE OF CONNECTICUT
DO NOT RECORD
INFORMATION SHEET
FOR PC-500, Application/
COURT OF PROBATE
[Type or Print in Black Ink.]
Removal of Guardian
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: ____________________________________________________