Application and Consent Termination of Parental Rights With Stepparent, Co-Parent or Relative Adoption

Filing this termination of parental right is necessary in an adoption case.

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CONNECTICUT PROBATE COURTS	 	Petition/Consent Termination of 	 	
Parental Rights 	AND	 Stepparent, 	
Co	-Parent or Relative Adoption	 	
PC	-601 REV. 10/16 	 	
 	RECEIVED	: 	
      	Instructions: 1) A parent or guardian, or other authorized person or agency under C.G.S. section 45a- 715, may use this 	
form to petition for 1) termination of parental rights of a parent or parents of a minor child  based on 
consent of the parent to be terminated AND 2) an adoption by a stepparent, co -parent or relative.  The 
relative must be a person descended from a common ancestor, whether by blood or adoption , but not 
more than three generations removed from the child.   	
2) The petition shou	 ld be filed in the court for the probate district in which  the adoptive parent resides or in
the case of a minor who is under the guardianship of any chi ld care facility or child-placing agency, in the 
district in which the main or local office of the agency is located.       
3 ) The following documents should be filed with the petition:  a) A long -fo r	
 m birth certificate, b)  JD -FM -
164, Affidavit Concerning Children , c) a statement of facts  concerning the consent termination and  the 
Affidavit of Consent to Termination of Parental Rights, JD-JM- 60, d) Adoption Data Sheet, PC-680,        e ) 
Agreement of Adoption, PC -681. 
4 ) For  m	
 ore information, see C.G.S. sections 45a -715  et  seq .,  45a -724 et seq.,  46b -115 et  seq ., and 52 -231a,
and Probate Court Rule s of Procedure, rule 4o.  	
5) Type or print the form in ink.	 Use an additional sheet	, or 	Second Sh	eet, 	PC	-180,	 if more space is needed	.	
Probate Court Name    	District Number   In the Matter of (List minor’s name and address where minor is 
residing.) 
 Hereinafter 	

referred to as the minor chid.	Plac	 e of Birth of Minor 
Child   Birth Date
 of Minor 
Child  
Tribe and Reservation  of Minor Child, if an Indian Child as defined by 25 U.S.C.  section 1903 (List name and 
address .) 
Jurisdiction based on:  
        Adoptive parent resides in the probate district  
        Minor child is under the guardianship of a duly -licensed child care or child- placing agency, which has an office in the   
probate district.   
Petitioner (List name, address and telephone number , and  the nature of the relationship to the minor child. ) 
Parents of Minor Child (For each parent, list name, address, telephone number, date of birth, military service of United 
States or Allied Nation (50 U.S.C. App. 520),  Indian tribe and reservation, if a member as defined by 25 U.S.C. section 
1903, and  whether the parent is legally incompetent. Include any putative father of a child born out of wedlock. C.G.S. 
section 45a- 716 (b) (2))  
1 .        a. Relationship to m inor c hild:  
b .Date of  birth :
c .In military service of US or Allied Nation     Yes       No  
d . Indian  tribe or r eservation:	
e. Legally	  incompetent   Yes       No	 	
  ____________________________________________________________________________	  Petition/Consent Termination of Parental Rights AND Stepparent, Co-P
arent or Relative Adoption     PC-601  Page 1 of 4       CONFIDENTIAL

CONNECTICUT PROBATE COURTS	 	Petition/Consent Termination of 	 	
Parental Rights 	AND	 Stepparent, 	
Co	-Parent or Relative Adoption	 	
PC	-601 REV. 10/16 	 	
2.        a. Relationship to m inor child: 
b .Date of  birth :
c . In military service of US or Allied Nation:       Yes       No
d . Indian  tribe or r eservation:
e . Legally incompetent    Yes       No  
Her

einafter referred to as the respondent (s) .       
If  a  parent  listed above is a minor or legally  incompetent , list the parents or g uardian/conservator for the parent 
( Include the name, address, telephone number and relationship.)   
1. 
2. 
Name of parent whose parental rights were previously terminated . (Provide a copy of the court decree.)  
Adoptive Parent (s) (List name, address and tel ephone number  and the nature of the relationship to the minor child)  
Guardian of the p erson of the minor, if not a parent  (For each guardian, list name, address, telephone number 
and date of appointment as guardian.) 
Child -placing a gency involved with the minor child, if not the petitioner ( List name, address and telephone number.) 
The petitioner represents that: 
      __________________________________________________ consent(s) to termination of his or her parental rights 
with respect to minor child. (Affidavit/ Consent to Termination of Parental Rights, JD -JM -60, and a statement of facts  must 
accompany  this petition.)   
  And  (C heck one of the following.)  
        The sole parent of the minor child has entered into an Adoption Agreement for the adoption of the minor child with  his or her spouse.  The sole parent is not relinquishing parental rights to the child.  
 The sole parent of the child has entered into an Adoption Agreement for the adoption of the minor child with a  person who shares parental responsibility for child with such parent. The sole parent is not relinquishing parental 
rights to the child.   	
 The guardian (s) of the person  of t	 he minor child have entered into an Adoption Agreement for the adoption of the 
minor child with the adoptive parent (s), one of whom is a relative by blood or adoption, descended from a common 	
ancestor not more than three generations removed from the 	minor child.	  Petition/Consent Termination of Parental Rights AND Stepparent, Co-P
arent or Relative Adoption     PC-601  Page 2 of 4       CONFIDENTIAL

CONNECTICUT PROBATE COURTS	 	Petition/Consent Termination of 	 	
Parental Rights 	AND	 Stepparent, 	
Co	-Parent or Relative Adoption	 	
PC	-601 REV. 10/16 	 	
The information contained in the Adoption Data Sheet, PC-680 and other documents submitted with the petition is true 
and complete to the best knowledge and belief of the petitioner.  
T he termination of parental rights of the parent(s) , ______________________________________________, and 
adoption by the adoptive parent (s) is in the best interest s of the child.  
Joinder and Consent of Minor Child  
I, the undersigned minor child, being at least 12 years of age, do join in the petition for termination of parental 
rights and consent to adoption by the proposed adoptive parent (s).  C.G.S. sections 45a-715 and 45a- 724. 
        	Signature of Minor Child  	  Duly Acknowledged Before Me  	
T ype or Print  Name 	
Date     Judge, Clerk, Public Notary, Comm. Sup. Ct.  	
The 	petitioner further represents that to the best of his or her knowledge and belief:	 	
The minor child          has resided  	         has not resided    in Connecticut continuously for the last six months. 	
There       is a proceeding         is no proceeding   pending or contemplated in Connecticut or any other state affecting th	e 	
custody of the minor child. 
There          has been a proceeding           has not been a proceeding      in the past in Connecticut or any other state 
affecting the custody of the minor child.  
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          is not      a current protective order or restraining order involving any party. If so, please atta	ch. 	
The minor child           is            is not       the subject of a pre- existing child support order. 
WHEREFORE, the p etitioner requests that the court terminate the parental rights of _________________________  , 
and  approve the Adoption Agreement on file.  
       The petitioner further requests that the court change the name of the minor child to: ________________________.  	
  The representations made in this petition are made under the penalt	y of false statement.	 	
Signature of Petitioner 	
T ype or Print  Name 	
Date  	
Consent to Termination  
I consent to the termination of my parental rights with respect to the minor child. ( Any consent to termination of 
parental rights must be accompanied by an Affidavit/ Consent to Termination of Parental Rights, JD -JM -60. C.G.S. 
section 45a- 715. A parent may waive personal service by filing a W aiver of Personal or Abode Service/Parental Rights 
Matter, PC -633. ) 
Signature of Parent          Duly Acknowledged Before Me 	
T ype  or Print  Name 	
Date    Judge, Clerk, Public Notary, Comm. Sup. Ct.  	
Signature of Parent       Duly Acknowledged Before Me 
T ype or Print  Name 	
Date     Judge, Clerk, Public Notary, Comm. Sup. Ct.   Petition/Consent Termination of Parental Rights AND Stepparent, Co-P
arent or Relative Adoption     PC-601  Page 3 of 4       CONFIDENTIAL

CONNECTICUT PROBATE COURTS	 	Petition/Consent Termination of 	 	
Parental Rights 	AND	 Stepparent, 	
Co	-Parent or Relative Adoption	 	
PC	-601 REV. 10/16 	 	
Legal Effect s of  a Termination of Parental Rights Decree  
Termination of parental rights means “ the complete severance by court order of the legal relationship,  with all of its rights 
and responsibilities between the child and his 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. ” C.G.S.  section 45a- 707(8). (Inheritance 
rights cease upon adoption.) No action  taken with respect to the termination of parental rights of one parent affects the 
parental rights of the other parent.  	
Upon a d	

ecree of termination of parental rights, the parent will NO LONGER have the following rights and responsibilities 
with  respect to the minor child who is the subject of the decree:  
• The legal right to custody, guardianship or control of the minor  child. The parent will have no legal right to
care for the minor  child or to  make any decisions on behalf of the minor  child. 
• The legal right to the minor  child's birth certificate.
• The legal right to any state and federal benefits the parent may have been receiving for the minor  child.
• The legal responsibility to support the m inor child and to pay for the minor child's maintenance, medical and
other expenses, but the  parent MAY be responsible for support of the minor  child until the effective date of the
termination.
• The legal responsibility to care for the minor  child or make any decisions on his or her behalf .	
Furthermore, upon a decree of termination, the minor  child will be legally free for adoption, and the parent will have no 
right to notice of the adoption proceedings nor any right to participate in the proceedings.	  Petition/Consent Termination of Parental Rights AND Stepparent, Co-P
arent or Relative Adoption     PC-601  Page 4 of 4       CONFIDENTIAL

CONNECTICUT PROBATE COURTS	 	
CONFIDENTIAL INFORMATION/Petition/	 	
Consent Termination of Parental Rights 	 	
AND Stepparent, Co	-Parent or Relative Adoption	 	
PC	-601C NEW 	10/16	  FOR COURT USE ONLY 	
 	RECEIVED
: 
Probate Court Name    District Number 
In the Matter of              
  , a  minor child . 
The

 social security numbers of the following persons are required in connection with this proceeding.  
1) Moth

er/ Parent 1 :
a. Name  ________________________________________________________________________\
___________
Soci

al Security Number   _____________________________________________________________________ 
2) Fath

er/ Parent 2 :
a. Name  ________________________________________________________________________\
___________
Soci

al Security Number   _____________________________________________________________________ 
3) Ado

ptive Parent( s)
a. Name  ________________________________________________________________________\
___________
Soci

al Security Number  ______________________________________________________________________ 
b. Name   ________________________________________________________________________\
__________
Soci

al Security Number  ______________________________________________________________________ 
_______________________________________________________________________________________________  
Confidential Information/Petition/Consent Termination of Parental Rights AND  Stepparent,  Co -Parent              PC -60 1C 
or Relative Adoption