Free PC-301 - Connecticut

APPLICATION FOR VOLUNTARY REPRESENTATION BY CONSERVATOR PC-301 REV. 10/08

STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink.]

RECORDED:

TO: COURT OF PROBATE, DISTRICT OF IN THE MATTER OF [Name, address, zip code, and telephone number.]

DISTRICT NO. PETITIONER'S SOCIAL SECURITY NUMBER PETITIONER'S DATE OF BIRTH

Hereinafter referred to as the petitioner. 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 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 a patient of the Veterans' Home and Hospital, Rocky Hill, CT C.G.S. §45a-649. Is not presently under conservatorship.

Does Has Is Is Is

THE PETITIONER FURTHER REPRESENTS that the spouse and closest relatives, if any, of said petitioner are as written above. WHEREFORE, THE PETITIONER REQUESTS that this Court appoint the proposed conservator named below or some other suitable person as: Conservator of the estate of said petitioner to carry out the following duties and authorities:

Conservator of the person of said 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 said position of trust. Signature ............................................................................. Name [Type or print] Address: Telephone Number:
ATTORNEY FOR PETITIONER [Name, address, zip code, telephone number, and juris number.]

Signature ............................................................................

*Please provide copies of these documents, if available. APPLICATION FOR VOLUNTARY REPRESENTATION BY CONSERVATOR PC-301
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