APPLICATION/APPOINTMENT OF TEMPORARY CONSERVATOR PC-302 REV. 10/08 TO: COURT OF PROBATE, DISTRICT OF IN THE MATTER OF
STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink.]
RECORDED:
DISTRICT NO. RESPONDENT'S SOCIAL SECURITY NUMBER RESPONDENT'S DATE OF BIRTH RESPONDENT'S PRESENT ADDRESS [If different]
Hereinafter referred to as the respondent, in a proceeding for involuntary representation. RESPONDENT'S RESIDENCE ADDRESS
RESPONDENT'S DOMICILE ADDRESS [If different]
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: Is Is not domiciled in Connecticut. 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.]* has has
and real property with
has not appointed a health care representative. [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.]* 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.] [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 Estate. Conservator of the Person. The representations contained herein are made under the penalties of false statement.
Date:
.................................................................................. Petitioner:
PROPOSED TEMPORARY CONSERVATOR(S) If appointed, I/we will accept said position(s) of trust, as temporary conservator(s) of the:
Person [Complete this section.] Estate [Complete this section.]
Signature .................................................................................. Name [Type or print] Address Telephone number:
ATTORNEY FOR THE PETITIONER [Name, complete address, telephone number, and juris number]
Signature ......................................................................
ATTORNEY FOR THE RESPONDENT [Name, complete address, telephone number, and juris number]
*Please provide copies of these documents, if available.
APPLICATION/APPOINTMENT OF TEMPORARY CONSERVATOR PC-302
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