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Application For Voluntary Representation By Conservator PC-301 - Connecticut
| Application For Voluntary Representation By Conservator Form. This is a Connecticut form and can be used in Probate Statewide . |
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APPLICATION FOR VOLUNTARY REPRESENTATION BY CONSERVATOR PC-301 REV. 1/13 Page 1 of 2 STATE OF CONNECTICUT COURT OF PROBATE RECORDED: [Type or print in black ink. Complete Confidential Information Sheet for PC-301 on last page.] TO: COURT OF PROBATE, IN THE MATTER OF [Name, address, zip code and telephone number.] Hereinafter referred to as the petitioner. DATE OF BIRTH DISTRICT NO. SPOUSE [Name, address, zip code and telephone number] PERSONS TO WHOM NOTICE SHOULD BE GIVEN: SPOUSE, 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 petitioner.] C.G.S. § 45a-646. [To give further details, use Second Sheet, PC-180.] THE PETITIONER REPRESENTS that he/she: Is now living at the present address written above and has domicile in the town written above. Has not executed a living will. Has Has Has not appointed a health care representative. [ Include name and address. If unknown, so state.]* Has Has Has not appointed a health care agent. [Include name and address. If unknown, so state. ]* Has not executed a power of attorney for health care decisions. [Include name and address of person appointed to act. If unknown, so state.] Does Has Is Is Does Does not own real property. C.G.S. § 45a-658. Has not received public assistance or institutional care from the State of Connecticut. Conn. Gen. Statutes Chapter 302. Is not a veteran or beneficiary receiving payments under any account from the Veterans' Administration. C.G.S. § 45a-593. Is not receiving aid or care from the Veterans' Home and Hospital, Rocky Hill, CT C.G.S. § 45a-649. Does not have a federal fiduciary. [Include name and address of person appointed to act. If unknown, so state.] Is Is not presently under conservatorship. *Please provide copies of these documents, if available. THE PETITIONER FURTHER REPRESENTS that the spouse and closest relatives, if any, of said petitioner are as written above. APPLICATION FOR VOLUNTARY REPRESENTATION BY CONSERVATOR PC-301 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR VOLUNTARY REPRESENTATION BY CONSERVATOR PC-301 REV. 7/12 Page 2 of 2 STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink.] RECORDED: WHEREFORE, THE PETITIONER REQUESTS that this court appoint the proposed conservator named below or some other suitable person as: Conservator of the estate of the petitioner to carry out the following duties and authorities: Conservator of the person of the petitioner to carry out the following duties and authorities: AND THAT probate bond of the conservator with suitable surety be fixed at $ the conservator be excused from furnishing probate bond. The representations contained herein are made under the penalties of false statement. Date: ....................................................................................... Petitioner: PROPOSED CONSERVATOR If appointed, I will accept the position of trust. Signature ............................................................................. Name [Type or print] Address: Telephone Number: ATTORNEY FOR PETITIONER [Name, address, zip code, telephone number, and juris number.] Signature ............................................................................ APPLICATION FOR VOLUNTARY REPRESENTATION BY CONSERVATOR PC-301 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL INFORMATION SHEET FOR PC-301, Application for Voluntary Representation by Conservator REV. 1/13 STATE OF CONNECTICUT COURT OF PROBATE [Type or Print in Black Ink.] DO NOT RECORD _____________________________________________________________________________________ Court, of Probate ______________________________________________ District The social security number of the petitioner is required in connection with this proceeding. In the Matter of: ______________________________________________________, petitioner. Social Security Number: ________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com
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