AFFIDAVIT IN LIEU OF ADMINISTRATION PC-212 REV. 10/08
STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink. File in duplicate.] [Use Second Sheet, PC-180, for additional data.] DISTRICT NO.
TO: COURT OF PROBATE, DISTRICT OF
IN THE MATTER OF [Include all names and initials under which any asset was held.]
SOCIAL SECURITY NO.
Hereinafter referred to as the decedent. DECEDENT'S RESIDENCE AT TIME OF DEATH [Include full address.]
DATE OF DEATH
PETITIONER [Name, address, zip code, and telephone number]
RELATIONSHIP TO DECEDENT, if any
THE PETITIONER under oath hereby applies to the court of probate for authorization to sell and/or transfer personal property of the decedent without administration or probate of will and states that: The petitioner is the surviving spouse of said decedent. There is no surviving spouse, and the petitioner is a next of kin of said decedent. There is no surviving spouse or next of kin, or such surviving spouse or next of kin has refused such affidavit, and the petitioner is a suitable person with sufficient interest for the following reason: No application for settlement of the estate is pending in any court of probate. The decedent died owning no real property, other than survivorship property, if any, in the State of Connecticut. The market value of the personal property listed below does not exceed $40,000. The decedent did did not ever receive aid or care from the State of Connecticut. [If affirmative,check appropriate box(es) below.] State of Connecticut Department of Veterans' Affairs C.G.S. §45a-355. (Rocky Hill facility) The decedent left a will dated The decedent left no will. The decedent died owning the following personal property: [List specific identifying numbers or information.] DESCRIPTION FAIR MARKET VALUE $0.00 $0.00 $0.00 $0.00 $0.00 Total
,which is not being presented for probate.
According to the information and belief of the petitioner, all debts of the decedent and claims against the estate are as follows: NATURE OF CLAIM CLAIMANT AMOUNT[If paid, indicate payor.] Funeral Expenses $0.00 Administration Expenses [i.e. court costs and attorney's fees ] Debts due for Last Sickness Other claims
The funeral director has not been paid, and the Court is requested to order payment from the assets listed above by: a) direct transfer or b) sale of assets. The creditors to whom debts are due for last sickness have not been paid, and the Court is requested to order payment from the assets listed above by: a) direct transfer or b) sale of assets. The debts or claims listed above have been paid in the manner prescribed by C.G.S.§45a-365. [Note: Each payor NOT seeking reimbursement must sign the waiver on Form PC-212A.] Listed assets exceed listed debts and claims, and all heirs-at-law and proposed distributees are listed on form PC-212A attached hereto. One or more of the children listed on PC-212A are not also issue of the surviving spouse. WHEREFORE, the undersigned, in lieu of filing an application for administration or probate of will, petitions the Court of Probate to issue a decree authorizing the holder of such property or the registrant thereof, including the authority issuing the registration, to transfer the same or pay the amount thereof and/or to sell the same and pay the proceeds thereof to the undersigned or as indicated above. ................................................................................ Petitioner: SUBSCRIBED AND SWORN TO BEFORE ME DATE ............................................................................................. Judge, Ass't Clerk, Notary Public, Comm. Sup. Ct.
AFFIDAVIT IN LIEU OF ADMINISTRATION PC-212