Free PC-700 - Connecticut

APPLICATION/GUARDIANSHIP OF PERSON WITH MENTAL RETARDATION PC-700 REV. 10/07

STATE OF CONNECTICUT
RECORDED(CONFIDENTIAL VOLUME):

COURT OF PROBATE [Type or print in black ink.] DISTRICT NO. RESPONDENT'S SOCIAL SECURITY NUMBER
RESPONDENT'S DATE OF BIRTH

TO: COURT OF PROBATE, DISTRICT OF IN THE MATTER OF

Hereinafter referred to as the respondent. PRESENT ADDRESS OF RESPONDENT [If institutionalized, give name and address of institution.]

PETITIONER [Name, address, zip code, and telephone number]

RESPONDENT'S TOWN OF DOMICILE

RELATIONSHIP OF PETITIONER TO RESPONDENT

PERSONS TO WHOM NOTICE SHOULD BE GIVEN: RESPONDENT, SPOUSE, AND PARENTS [if any, and provided they are not the applicants], CHILDREN [if any], SIBLINGS OR THEIR REPRESENTATIVES [if any and only if respondent has no living parents], DEPARTMENT OF DEVELOPMENTAL SERVICES REGIONAL DIRECTOR, PERSON IN CHARGE OF THE INSTITUTION WHERE THE RESPONDENT CURRENTLY RESIDES, ATTORNEY FOR THE RESPONDENT [if any], and ANY OTHER PERSONS HAVING AN INTEREST IN THE RESPONDENT. [Give names, addresses, zip codes, and relationships to respondent. If attorney for respondent, list juris number.] C.G.S. §45a-670.

Additional data [on Second Sheet, PC-180] ,if any, is made a part hereof. THE PETITIONER REPRESENTS that: There is is not a plenary guardian, limited guardian, or conservator for the respondent in any jurisdiction. [If so, list status, location, court, and date of court decree on Second Sheet, PC-180 .] The respondent is is not able to attend a hearing at the court. The respondent, by reason of the severity of his or her mental retardation, is able to do some, but not all, of the tasks necessary to meet essential requirements for his or her physical health or safety or to make some, but not all, informed decisions about matters related to his or her care (limited guardianship) OR is totally unable to meet essential requirements for his or her physical health or safety and totally unable to make informed decisions about matters related to his or her care (plenary guardianship). Please list the specific areas of protection and assistance required for the respondent by checking the appropriate boxes below.The Probate Court may give a guardian the power to assure and/or consent to the following: residence outside the natural family home; specifically designed educational, vocational, or behavioral programs; the release of clinical records and photographs; routine, elective and emergency medical and dental care; other specific limited services necessary to develop or regain to the maximum extent possible the ward's capacity to meet essential requirements.

A plenary guardian will be given all of the above powers; a limited guardian will be given only those powers deemed necessary by the Court. C.G.S. §45a-677. Plenary and limited guardians also have a duty to assure the care and comfort of the ward within the scope of their appointment and within the limitations of the resources available to the ward, either through his or her own estate or by reason of public or private assistance. WHEREFORE THE PETITIONER REQUESTS that this Court appoint a limited plenary standby guardian(s) of the person. The representations contained herein are made under the penalties of false statement.

DATE:

.................................................................................. Petitioner:

Proposed Type Name:

IF APPOINTED, I WILL ACCEPT THE POSITION OF TRUST AS DETERMINED BY THE COURT. Proposed Standby Guardian LIMITED PLENARY Guardian Signed...............................................................................

Signed...............................................................................

Type Name:
Address and Zip Code:

Address and Zip Code:

Telephone Number: Telephone Number: APPLICATION/GUARDIANSHIP OF PERSON WITH MENTAL RETARDATION PC-700 RESET