AFFIDAVIT/APPOINTMENT OF COMMISSIONER OF SOCIAL SERVICES AS CONSERVATOR PC-310 REV. 7/93 STATE OF CONNECTICUT RECORDED: COURT OF PROBATE [Type or print in black ink.] [Attach to Application for Appointment of Conservator, PC-300] DISTRICT NO. DATE OF BIRTH TO: COURT OF PROBATE, IN THE MATTER OF Hereinafter referred to as the respondent. PETITIONER THE PETITIONER REPRESENTS that due diligence has been used to find a suitable conservator for the above-named respondent and describes efforts made as follows: ["Due diligence" means that a thorough search has been made to find an available and suitable conservator, and no suitable conservator who is willing to serve has been found.] THE PETITIONER FURTHER REPRESENTS that the health and welfare of the respondent is in jeopardy without the appointment of a conservator, by reason of the following conditions: THE PETITIONER FURTHER REPRESENTS that the respondent has liquid assets, excluding burial insurance in an amount up to $1,500, which do not exceed $1,500. [Liquid assets means all income and assets readily convertible into cash, excluding real property, and including, but not limited to, cash, bank accounts, stocks, credit union shares, present interest in estates, the cash value of life insurance, and the cash value of burial insurance in an amount over $1,500. ] .......................................................................... Petitioner: SUBSCRIBED AND SWORN TO BEFORE ME DATE .......................................................................................................... Judge Clerk Ass't Clerk AFFIDAVIT/APPOINTMENT OF COMMISSIONER OF SOCIAL SERVICES AS CONSERVATOR PC-310 American LegalNet, Inc. www.FormsWorkFlow.com