APPLICATION FOR APPOINTMENT RECORDED: STATE OF CONNECTICUT OF CONSERVATOR COURT OF PROBATE PC-300 REV. 7/12 Page 1 of 3 [Type or print in black ink. Complete Confidential Information Sheet for PC-300 on last page.] TO: COURT OF PROBATE, DISTRICT NO. IN THE MATTER OF [If a conservator has been appointed in any other Hereinafter referred to as the respondent, in a proceeding for involuntary representation. court, please list the court's name.] SPOUSE [Name, address, zip code, and telephone number] PETITIONER [Name, address, zip code, and telephone number] RESPONDENT'S RESIDENCE ADDRESS RELATIONSHIP OF PETITIONER TO RESPONDENT RESPONDENT'S DOMICILE ADDRESS [If different] RESPONDENT'S PRESENT ADDRESS [If different] 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. To give further details, use Second Sheet, PC-180.] THE PETITIONER FURTHER REPRESENTS that said respondent: Is Is not domiciled in Connecticut. Has Has not designated a conservator as provided by C.G.S. § 45a-645. [Include name and address. If unknown, so state.] If the respondent has designated a conservator, and the proposed conservator named herein is not the designated conservator, explain by separate document. Has not executed a living will.* 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 Has not executed a power of attorney for health care decisions. [Include name and address of person appointed to act. If unknown, so state.]* Has not executed a durable power of attorney. [Include name and address of person appointed to act. If unknown, so state.]* Has Does Does not own real property. C.G.S. § 45a-658. [Include address(es) if applicable.] Has Has not received public assistance or institutional care from the State of Connecticut. Conn. Gen. Statutes Chapter 302. Is Is not receiving aid or care from the Veterans' Home and Hospital, Rocky Hill, CT. C.G.S. § 45a-649. Is Is not a veteran or beneficiary receiving payments under any account from the Dept. of Veterans' Affairs. C.G.S. § 45a-593. Does Does not have a federal fiduciary. [Include name and address of person appointed to act. If unknown, so state.] Is Is not a patient in a hospital or institution. C.G.S. § 45a-649. *Please provide copies of these documents, if available. APPLICATION FOR APPOINTMENT OF CONSERVATOR PC-300 Continued American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR APPOINTMENT OF CONSERVATOR PC-300 REV. 7/12 Page 2 of 3 STATE OF CONNECTICUT RECORDED: COURT OF PROBATE [Type or print in black ink.] THE PETITIONER FURTHER REPRESENTS that said respondent: Is Is not in an institution for the mentally ill or mentally deficient in this state. C.G.S. § 4a-17. If so, the respondent is in such institution on the following basis: Confined by order of a court. C.G.S. § 4a-17 Confined under emergency certificate of a physicia C.G.S.§ 4a-17. Ғ Voluntary admission. 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.] Is not able to request or obtain an attorney. C.G.S. § 45a-649. Is Is Is not able to pay for the services of an attorney. [Submit Request/Order Waiver of Fees, PC-184A.] THE PETITIONER FURTHER REPRESENTS THAT: The mental, emotional,and/or physical condition that prevents the respondent from performing the necessary and proper functions for his or her well-being is as follows: [Describe briefly.] [If the application is for the appointment of a CONSERVATOR OF THE ESTATE, fill in Part "A" below. If the application is for the appointment of a CONSERVATOR OF THE PERSON, fill in Part "B." If the application is for BOTH conservator of the estate and conservator of the person, Parts "A" and "B" must both be completed.] A - Conservator of the Estate The condition described above results in the respondent being unable to receive and evaluate information or make or communicate decisions to such an extent that the person is unable, even with appropriate assistance, to perform the following functions inherent in managing his or her affairs: AND: the respondent has property rights that will be wasted or dissipated unless adequate property management is provided. funds are needed for the support, care, or welfare of the respondent, and the respondent is unable to take the necessary steps to obtain or provide such funds. funds are needed for the support, care, or welfare of those entitled to be supported by the respondent, and the respondent is unable to take the necessary steps to obtain or provide such funds. The estimated value of the respondent's property is: Personal Property: $ Real Property: $ B - Conservator of the Person The condition described above results in the respondent being unable to receive and evaluate information or make or communicate decisions to such an extent that the person is unable, even with appropriate assistance, to meet the following essential requirements for personal needs: Continued APPLICATION FOR APPOINTMENT OF CONSERVATOR PC-300 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR APPOINTMENT OF CONSERVATOR PC-300 REV. 7/12 Page 3 of 3 STATE OF CONNECTICUT RECORDED: COURT OF PROBATE WHEREFORE, THE PETITIONER REQUESTS that this court appoint the proposed conservator named below or some other suitable person as conservator of the aforesaid respondent. [NOTE: If the Commissioner of Social Services is the proposed conservator of the estate and/or person, attach Affidavit/Appointment of Commissioner of Social Services as Conservator, PC-310. C.G.S. § 45a-651.] The representations contained herein are made under the penalties of false statement. ....................................................................... Petitioner: Date: PROPOSED CONSERVATOR(S) If appointed, I will accept the position of trust. Signature ....................................................................................... Signature ....................................................................................... Name [Type or print] Address: Telephone Number(s): Telephone Number(s): ATTORNEY FOR PETITIONER [Name, address, zip code, telephone number, and juris number] ATTORNEY FOR RESPONDENT [Name, address, zip code, telephone number, and juris number] EXAMINING PHYSICIAN [Name, address, zip code, and telephone number] C.G.S. § 45a-650. APPLICATION FOR APPOINTMENT OF CONSERVATOR PC-300 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL STATE OF CONNECTICUT DO NOT RECORD INFORMATION SHEET FOR PC-300, Application for COURT OF PROBATE [Type or Print in Black Ink.] Appointment of Conservator NEW 7/12 _____________________________________________________________________________________ Court of Probate, ______________________________________________ District The social security number and date of birth of the respondent are required in connection with this proceeding. In the Matter of: ______________________________________________________ , respondent. Social Security Number: __________________________________ Date of Birth: _________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com