CONNECTICUT PROBATE COURTS Request for Order of Distribution PC - 212A REV. 1/19 Request for Order of Distribution PC - 212A Page 1 of 3 RECEIVED: Instructions: 1)A petitioner filing a PC-212, Affidavit in Lieu of Probate of Will/Administration, may use this form torequest an order of distribution if (a) assets exceed expenses and claims or (b) a person who paidexpenses or claims waives reimbursement for payment of the expense or claim.2)If the decedent left a will that provides for distribution different from that under the laws of intestacy,either (a) all heirs must waive the right to contest the will and sign Section A in the space provided, or(b) all persons entitled to a distribution under the will must consent to distribution in accordancewith the laws of intestacy and sign Section B in the space provided.3)For more information, see C.G.S. section 45a-273(d).4)Type or print the form in ink. Use an additional sheet, or PC-180, if more space is needed. Probate Court Name District Number Estate of Hereinafter referred to as the decedent Date of Death Heirs and Beneficiaries. Indicate any person who is under age 18 (include date of birth), any person in the military service or any person under conservatorship or legal disability. C.G.S. sections 45a-436, 45a-438 and 45a-439. Include the name, address and position of trust of the legal representative of any party who has been adjudicated incapable. 1.Heirs (Names and addresses.) Children of a deceased child If NO children or grandchildren, list surviving parents American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Request for Order of Distribution PC - 212A REV. 1/19 Request for Order of Distribution PC - 212A Page 2 of 3 If NO spouse, children, grandchildren or parents, list brothers and sisters or children of any deceased brother or sister (Identify relationship to decedent.) If NONE of the above apply, please refer to C.G.S. section 45a-439(a)(3) and provide a family tree. 2.Beneficiaries entitled to distribution under the will . (Names and addresses) The petitioner represents that: The decedent left no will, and the petitioner requests an order of distribution to the heirs in accordance with the laws of intestacy. One or more of the children of the decedent is not also the child of the surviving spouse. The decedent left a will dated that provides for distribution that is the same as under the laws of intestacy. The decedent left a will dated that provides for distribution different from that under the laws of intestacy and (Choose A or B): Section A. Heirs. Waiver and Consent to Distribution in Accordance with the Will. The undersigned, being each of the heirs, have read the will and hereby waive the right to contest the will and consent to distribution to the persons entitled to distribution in accordance with the terms of the will. Name: Name: Name: Name: Name: Name: Section B. Beneficiaries. Consent to Distribution in Accordance with the Laws of Intestacy. The undersigned, being each of the beneficiaries entitled to distribution under the will, have read the will and hereby consent to distribution to the heirs in accordance with the laws of intestacy. Name: Name: Name: Name: Name: Name: American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Request for Order of Distribution PC - 212A REV. 1/19 Request for Order of Distribution PC - 212A Page 3 of 3 The undersigned hereby waives reimbursement for payment of claims listed on form PC-212. Name: Name: Name: Name: Name: Name: WHEREFORE the petitioner requests that the court issue an order of distribution of the excess personal property of the decedent to: the heirs, the decedent having left no will or having left a will that provides for distribution that is the same as under the laws of intestacy. the beneficiaries entitled to distribution in accordance with the will as described in Section A, above. the heirs in accordance with the laws of intestacy as described in Section B, above. The representations made in this petition are made under penalty of false statement. Signature of Petitioner Type or Print Name Date American LegalNet, Inc. www.FormsWorkFlow.com