STATE OF CONNECTICUT APPLICATION/ANCILLARY RECORDED: PROBATE OF WILL COURT OF PROBATE PC-201 REV. 7/12 Page 1 of 2 [Type or print in black ink. File in duplicate. Complete Confidential Information Sheet for PC-201 on last page. Use Second Sheet, PC-180, for additional data.] TO: COURT OF PROBATE, DISTRICT NO. ESTATE OF [Include all names and initials under which any asset was held.] DATE OF DEATH DECEDENT'S RESIDENCE AT TIME OF DEATH [Include full address.] PETITIONER [Name, address, and zip code ] SURVIVING SPOUSE [Name, address, and zip code. If no surviving spouse, so state.] JURISDICTION APPERTAINS TO THIS COURT BASED ON THE FOLLOWING: [C.G.S. § 45a-287] The decedent last resided in this district. The decedent has real or tangible personal property located in this district. The decedent has maintained bank accounts or evidence of other tangible property in this district. An executor or trustee named in the will resides in this district or, in the case of a bank or trust company, has an office in this district. A cause of action in favor of the decedent arose in this district, or a debtor of the decedent resides or has an office in this district. HEIRS, NEXT OF KIN, BENEFICIARIES, THE DECEDENT'S CONSERVATOR(S), AND TRUSTEES, if any. Indicate any person who is under conservatorship, legaOҒ disability, or in the military service. C.G.S. §§ 45a-436, 45a-438, 45a-439. 1. HEIRS AND NEXT OF KIN [Give names and addresses.] Spouse [Name only] Children [Include date of birth of any child under age 18.] Children of a deceased child [Include date of birth of any child under age 18.] APPLICATION/ANCILLARY PROBATE OF WILL PC-201 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CONNECTICUT APPLICATION/ANCILLARY PROBATE OF WILL PC-201 REV. 7/12 Page 2 of 2 RECORDED: COURT OF PROBATE [Type or print in black ink.] IF NO spouse, children, grandchildren or parents, give name(s) and address(es) of decedent's brother(s) and sister(s) or children of any deceased brother or sister. IF NONE of the above apply, please refer to C.G.S. § 45a-439(a)(3) and provide a family tree. 2. BENEFICIARIES, including trustees [Give name(s) and address(es) and paragraph in Will where interest in the estate may arise. It is not necessary to list the address if it is already listed above.] 3. DECEDENT'S CONSERVATOR(S) [Give name(s) and address(es).] THE PETITIONER REPRESENTS that: No other application for ancillary probate has been filed in the State of Connecticut. Decedent, or spouse or children of the decedent, did did not ever receive aid or care from the State of Connecticut. State of Connecticut (D.A.S) Department of Veterans' Affairs C.G.S. § 45a-355. [If affirmative, check appropriate box(es).] THE PETITIONER HEREWITH PRESENTS to the court the duly authenticated and exemplified copy of the Last Will and Testament and codicils, if any, of the decedent dated and the record of the proceedings proving and establishing the same by a court of competent jurisdiction and REPRESENTS that the time for taking an appeal therefrom has has not expired, and no appeals are presently pending. Attached hereto is a complete statement of the property and estate of the decedent in Connecticut. C.G.S. § 45a-288. WHEREFORE, THE PETITIONER REQUESTS this court to order that said copies be filed and recorded and that letters ancillary testamentary be issued to the fiduciary named below. The representations contained herein are made under the penalties of false statement. ........................................................................... Petitioner: Date: PROPOSED FIDUCIARY IF APPOINTED, I WILL ACCEPT SAID POSITION OF TRUST. Signature ................................................................................ ................................................................................ [Type or print name under signature. ] Address and zip code: Fiduciary is is not a resident of the State of Connecticut. Telephone number: Fiduciary is Telephone number: is not a resident of the State of Connecticut. ATTORNEY FOR PROPOSED FIDUCIARY [Name, address, zip code, telephone number, Conn. Bar Juris No .] Each of the undersigned represents that he or she has examined the application and related documents and hereby WAIVES NOTICE OF HEARING upon said application and has NO OBJECTION to the granting and approval thereof. [ If space is insufficient, use General Waiver, PC-181. Please also type or print name.] ........................................................... ........................................................... APPLICATION/ANCILLARY PROBATE OF WILL PC-201 ........................................................... American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL INFORMATION SHEET FOR PC-201, Application/ Ancillary Probate of Will NEW 7/12 STATE OF CONNECTICUT DO NOT RECORD COURT OF PROBATE [Type or Print in Black Ink.] Court of Probate, ______________________________________________ District The social security number of the decedent is required in connection with this proceeding. In the Matter of: ______________________________________________________ , deceased Social Security Number: ________________________________ American LegalNet, Inc. www.FormsWorkFlow.com