Free PC-302 - Connecticut



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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 respon

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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File Size: 160.2 kB
Pages: 1
File Format: PDF
State: Connecticut
Category: Court Forms - State
Word Count: 610 Words, 4,176 Characters
Page Size: 612 x 1008 pts
URL

http://www.jud2.ct.gov/webforms/forms/pc-302ar.pdf