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Affidavit Of Financial Responsibility Form. This is a Connecticut form and can be use in Probate Statewide.
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Tags: Affidavit Of Financial Responsibility, PC-410, Connecticut Statewide, Probate
AFFIDAVIT OF FINANCIAL
RESPONSIBILITY - PERSONAL SURETY
PC-410 REV. 10/09
STATE OF CONNECTICUT
COURT OF PROBATE
[Type or print in black ink. ]
TO: COURT OF PROBATE, DISTRICT OF
DISTRICT NO.
DATE OF AFFIDAVIT
ESTATE OF/IN THE MATTER OF
FIDUCIARY [Name, address, and zip code]
POSITION OF TRUST
AMOUNT OF BOND
PROPOSED PERSONAL SURETY [Name, address, and zip code]
I, the proposed personal surety, submit this affidavit (1) as a true and accurate statement as to the assets shown and (2) as a true,
accurate, and complete statement of all of my liabilities as of the date of this affidavit. DATE AND SIGN ON PAGE TWO.
INSTRUCTIONS: All unsecured direct liabilities of the proposed personal surety must be shown. If any assets shown are owned jointly
in survivorship, all joint owners must become sureties and sign the affidavit. If any assets shown are owned as tenants in common with
others, then only the value of the share of the proposed surety shall be shown. Assets need be shown only to a total value of equity equal
to the sum of the amount of the probate bond required, plus the total of the unsecured direct liabilities of the proposed surety. Assets
may be shown in any of the categories listed. If an asset is listed which is security for a liability (e.g., mortgage, collateral loan, etc.),
only the excess of the value of such asset over the liability it secures shall be shown.
Give actual amounts. Do not approximate. Complete supporting schedules. If space is insufficient, attach supplemental schedule.
ASSETS
LIABILITIES
Current Assets:
1. Bank Deposits (Sch. 1) ....................
$
2. Notes Receivable (Good)
(amounts due within one year) (Sch. 2)...
3. Other Current Assets
(Sch. 7)..........................................
Marketable Securities:
4. Stocks and Bonds - Pledged
(Sch. 4A)........................................
5. Stocks and Bonds - Unpledged
(Sch. 4B) .......................................
Real Estate:
6. Enter Equity from Sch. 3.....................
Other Assets:
7. Life Insurance Cash
Surrender Value................................
8. Notes Receivable
(amounts due beyond one year)
(Sch. 2)..........................................
9. Other Stocks and
Bonds (Sch. 4C)................................
10. Miscellaneous Assets
(Sch. 7)........................................
11. TOTAL EQUITY VALUE OF
ASSETS (Lines 1-10) ....................$
SCHEDULE 1: DEPOSITS
(List Banks and Account Numbers)
Amount
12. Suretyship on Other Probate
Bonds...................................$
Unsecured Direct Liabilities:
13. Accounts Payable (Sch. 5)............
14. Unpaid Interest, Taxes,
etc.........................................
15. Notes Payable (Sch. 6).................
16. Other Direct Liabilities
(Sch. 7) ...................................
17. Total Amount of Suretyship
on Other Probate Bonds and
Unsecured Direct
Liabilities (lines 12-16) .........$
18. Amount of Assets Available
for this Suretyship
(line 11 minus line 17).................
19. TOTAL OF LINES 17
AND 18 .................................$
SCHEDULE 2: NOTES RECEIVABLE
(List Name and Address of Maker or Payor)
Total
AFFIDAVIT OF FINANCIAL RESPONSIBILITY - PERSONAL SURETY
Continued
PC-410
Amount Due on Note During
next 12
beyond12
months
months
Totals
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AFFIDAVIT OF FINANCIAL
RESPONSIBILITY - PERSONAL
SURETY PC-410 REV. 10/09 Page 2
STATE OF CONNECTICUT
COURT OF PROBATE
[Type or Print]
SCHEDULE 3: REAL ESTATE (List street, town, and state.) Indicate
type and use of property. If mortaged, give name of mortgagee.
Market
Value
Assessed
Value
SCHEDULE 4A: MARKETABLE STOCKS AND BONDS
-PLEDGED (List Number of Shares, Name of Security, & Market Value.)
Mortgage
Balance
Equity
SCHEDULE 5: ACCOUNTS PAYABLE
Amount
Total Amount:
If total amount exceeds $2,000, list creditors and
amounts below.
Total:
SCHEDULE 4B: MARKETABLE STOCKS AND
BONDS -UNPLEDGED (List Number of Shares,
Name of Security, and Market Value.)
SCHEDULE 6: NOTES PAYABLE (List Payees and
Addresses)
Amount
Total:
SCHEDULE 4C: OTHER STOCKS AND BONDS
-UNPLEDGED (List Number of Shares, Name of
Security, and Market Value.)
SCHEDULE 7: EXPLANATION OF LINES 3,10, &16
Total:
PLEASE ANSWER ALL OF THE QUESTIONS BELOW. IF THE ANSWER TO ANY QUESTION IS "YES," PLEASE EXPLAIN.
1. Are you presently or have you ever been surety on a probate bond in Connecticut?
Yes
No
2. Are you a co-maker on a note, or are you an endorser, guarantor, or otherwise contingently liable for the debts of another?
Yes
No
3. Do you have or anticipate unusual or above-normal demands on assets during the projected term of your suretyship, such as costs of college
education, medical expenses, responsibility for parents, plans for retirement, or contemplated major capital expenditures?
4. Are you a party in a lawsuit?
Yes
Yes
No
No
5. Are there any judgments outstanding against you?
Yes
6. Have you been declared bankrupt in the last fourteen years?
No
Yes
No
The representations contained herein are made under the penalties of false statement.
Date:
.................................................................................................
Proposed Personal Surety:
AFFIDAVIT OF FINANCIAL RESPONSIBILITY - PERSONAL SURETY
PC-410
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