AFFIDAVIT IN LIEU RECORDED: STATE OF CONNECTICUT OF PROBATE OF WILL/ADMINISTRATION PC-212 REV. 7/12 COURT OF PROBATE Page 1 of 2 [Type or print in black ink. File in duplicate.] [Complete Confidential Information Sheet for PC-212 on Page 3. Use Second Sheet, PC-180, for additional data.] TO: COURT OF PROBATE, DISTRICT NO. IN THE MATTER OF [Include all names and initials under which any asset was held.] Hereinafter referred to as the decedent. DECEDENT'S RESIDENCE AT TIME OF DEATH [Include full address.] PETITIONER [Name, address, zip code, and telephone number] DATE OF DEATH RELATIONSHIP TO DECEDENT, if any THE PETITIONER under oath hereby applies to the court of probate for authorization to sell and/or transfer personal property of the decedent without administration or probate of will and states that: The petitioner is the surviving spouse of said decedent. There is no surviving spouse, and the petitioner is a next of kin of the decedent. There is no surviving spouse or next of kin, or such surviving spouse or next of kin has refused such affidavit, and the petitioner is a suitable person with sufficient interest for the following reason: No application for settlement of the estate is pending in any court of probate. The decedent died owning no real estate, other than survivorship real estate, if any, in the State of Connecticut. The market value of the solely-owned assets listed below does not exceed $40,000. The decedent did did not ever receive aid or care from the State of Connecticut. [If affirmative,check appropriate box(es) below.] State of Connecticut Department of Veterans' Affairs C.G.S. § 45a-273(c). (Rocky Hill facility) The decedent left a will dated ,which is not being presented for probate. The decedent left no will The decedent died owning the following solely-owned assets: [List specific identifying numbers or information.] DESCRIPTION FAIR MARKET VALUE $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TOTAL AFFIDAVIT IN LIEU OF PROBATE OF WILL/ADMINISTRATION PC-212 $0.00 American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT IN LIEU OF PROBATE OF WILL/ADMINISTRATION PC-212 REV. 7/12 Page 2 of 2 RECORDED: STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink File in duplicate.] According to the information and belief of the petitioner, all debts of the decedent and claims against the estate are as follows: NATURE OF CLAIM CLAIMANT/CREDITOR AMOUNT[If paid,indicate payor.] Funeral Expenses $0.00 $0.00 Administration Expenses [i.e. court costs and attorney's fees] $0.00 $0.00 $0.00 Debts due for Last Sickness $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Other claims $0.00 $0.00 $0.00 The funeral director has not been paid, and the court is requested to order payment from the assets listed above by: a) direct transfer or b) sale of assets. The creditors to whom debts are due for last sickness have not been paid, and the court is requested to order payment from the assets listed above by: a) direct transfer or b) sale of assets. The debts or claims listed above have been paid in the manner prescribed by C.G.S.§ 45a-365. [Note: Each payor NOT seeking reimbursement must sign the waiver on Form PC-212A. Listed assets exceed listed debts and claims, and all heirs-at-law and proposed distributees are listed on form PC-212A attached hereto. One or more of the children listed on PC-212A is/are not also children of the surviving spouse. WHEREFORE, the undersigned, in lieu of filing an application for administration or probate of will, petitions the Court of Probate to issue a decree authorizing the holder of such property or the registrant thereof, including the authority issuing the registration, to transfer the same or pay the amount thereof and/or to sell the same and pay the proceeds thereof to the undersigned or as indicated above. The representations contained herein are made under the penalties of false statement. Date: ................................................................................ Petitioner: _______________________________________________________________________________________________ AFFIDAVIT IN LIEU OF PROBATE OF WILL/ADMINISTRATION PC-212 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL STATE OF CONNECTICUT DO NOT RECORD INFORMATION SHEET FOR PC-212, Affidavit in Lieu of COURT OF PROBATE Probate of Will/Administration [Type or Print in Black Ink..] NEW 7/12 _____________________________________________________________________________________ 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: ____________________________________________________________ _______________________________________________________________________________________________ AFFIDAVIT IN LIEU OF PROBATE OF WILL/ADMINISTRATION PC-212 American LegalNet, Inc. www.FormsWorkFlow.com