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Application Appointment Of Temporary Conservator PC-302 - Connecticut
| Application Appointment Of Temporary Conservator Form. This is a Connecticut form and can be used in Probate Statewide . |
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STATE OF CONNECTICUT APPLICATION/APPOINTMENT OF RECORDED: TEMPORARY CONSERVATOR COURT OF PROBATE PC-302 REV. 1/13 Page 1 of 2 [Type or print in black ink. Complete Confidential Information Sheet for PC-302 on last page.] TO:COURT OF PROBATE, DISTRICT NO. IN THE MATTER OF Hereinafter referred to as the respondent, in a proceeding for involuntary representation. RESPONDENT'S RESIDENCE ADDRESS DATE OF BIRTH RESPONDENT'S DOMICILE ADDRESS [If different] RESPONDENT'S PRESENT ADDRESS [If different] SPOUSE [Name, address, zip code and telephone number] PETITIONER [Name, address, zip code, and telephone number] RELATIONSHIP OF PETITIONER TO RESPONDENT [C.G.S. § 45a-654] PERSONS TO WHOM NOTICE SHOULD BE GIVEN: SPOUSE [If not the petitioner], CLOSEST RELATIVES [If none, so state], and INTERESTED PARTIES as defined in Probate Practice Book, Rule 3.1.02.[ Give names, addresses, zip codes, and relationships to respondent.(C.G.S. § 45a-649).] Additional data [on Second Sheet, PC-180], if any, is made a part hereof. THE PETITIONER REPRESENTS that said respondent: Has Has not been physically present in Connecticut for at least six consecutive months immediately before the filing of the application, including any periods of temporary absence. If not, attach completed form PC-300A. Does Does not have a conservator or guardian appointed in another state or Connecticut probate district. If "yes," indicate the appointing court: There is is not a proceeding pending for the appointment of a conservator or guardian in any other state or Connecticut probate district. If "yes," indicate the court in which the proceeding is pending: Is incapable of managing his/her affairs and has personal property with an estimated value of $ an estimated value of $ Is incapable of caring for himself/herself AND has has not designated a conservator as provided by C.G.S. §§ 45a-645 and 45a-650. has has not executed a living will.* has has not appointed a health care agent.[Include name and address. If unknown, so state.]* and real property with has has not appointed a health care representative. [Include name and address. If unknown, so state.]* *Please provide copies of these documents, if available. APPLICATION/APPOINTMENT OF TEMPORARY CONSERVATOR PC-302 Continued American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION/APPOINTMENT OF TEMPORARY CONSERVATOR PC-302 REV. 10/12 Page 2 of 2 has STATE OF CONNECTICUT COUR7 OF PROBATE [Type or print in black ink.] RECORDED: has not executed a power of attorney for health care decisions. [Include name and address of person appointed to act. If unknown, so state.]* is is not able to request or obtain an attorney. [C.G.S. § 45a-649.] is is not able to pay for the services of an attorney. [Submit affidavit of financial status. (C.G.S. § 45a-649).] is or is expected to become an inpatient or outpatient in a hospital, clinic, or other facility for the diagnosis, observation, or treatment of mental illness. [Note: If this box is checked, AND if consent or other authorization is being sought for (a) psychiatric medication treatment and/or (b) shock therapy, special statutory requirements must be met. The applicable forms (CM-42 or CM-46 for psychiatric medication and CM-44 for shock therapy), together with all supporting documentation, MUST be attached to this form. ALL of the documents filed in connection therewith will be recorded in a confidential volume.] *Please provide copies of these documents, if available. [Note: If Commissioner of Social Services is proposed conservator of estate and/or person, attach Affidavit, PC-310, C.G.S. § 45a-651.] Immediate and irreparable harm to the mental or physical health or financial or legal affairs of the respondent will result if a temporary conservator is not appointed. [Briefly describe reasons. Use Second Sheet, PC-180, if additional space is needed.] A report signed by the Connecticut-licensed physician who examined the respondent is attached and is part of this application. C.G.S.§ 45a-654. THE PETITIONER FURTHER REPRESENTS that the contents of this application are true to the petitioner's best knowledge and belief and requests that this court appoint the proposed temporary: Conservator of the Person Conservator of the Estate The representations contained herein are made under the penalties of false statement. Date: .................................................................................. Petitioner: PROPOSED TEMPORARY CONSERVATOR(S) If appointed, I/we will accept the position(s) of trust, as temporary conservator(s) of the: Person [Complete this section. ] Estate [Complete this section. ] Signature .................................................................................. Signature ...................................................................... Name [Type or print] Address: Telephone number: ATTORNEY FOR THE PETITIONER [Name, complete address, telephone number, and juris number] ATTORNEY FOR THE RESPONDENT [Name, complete address, telephone number, and juris number] APPLICATION/APPOINTMENT OF TEMPORARY CONSERVATOR PC-302 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL STATE OF CONNECTICUT DO NOT RECORD INFORMATION SHEET FOR PC-302, Application/ COURT OF PROBATE [Type or Print in Black Ink.] Appointment of Temporary Conservator REV. 1/13 _____________________________________________________________________________________ Court of Probate, ______________________________________________ District The social security number of the respondent is required in connection with this proceeding. In the Matter of: ______________________________________________________ , respondent. Social Security Number: ________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com
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