APPLICATION/ RECORDED: STATE OF CONNECTICUT ADMINISTRATION OR PROBATE OF WILL COURT OF PROBATE PC-200 REV. 7/12 [Type or print in black ink. File in duplicate.] Page 1 of 3 [Complete Confidential Information Sheet for PC-200 on last page. Use Second Sheet, PC-180 for additional data.] DISTRICT NO. TO: COURT OF PROBATE, ESTATE OF [Include all names and initials under which any asset was held.] DECEDENT'S RESIDENCE AT TIME OF DEATH [Include full address.] DATE OF APPLICATION DATE OF DEATH JURISDICTION BASED ON: Domicile in District [If domicile is Other [Please explain different than residence, please explain. ] other jurisdictional basis. ] Use Second Sheet, PC-180, for explanation. PETITIONER [Name, address, and zip code] SURVIVING SPOUSE [Name, address, and zip code. If there is no surviving spouse, so state.] HEIRS, NEXT OF KIN, BENEFICIARIES, THE DECEDENT'S CONSERVATOR(S), AND TRUSTEES, if any. Indicate any person who is under conservatorship, lega disability, or in the military service. C.G.S. §§ 45a-436, 45a-438, 45a-439. 1. HEIRS AND NEXT OF KIN [Give names and addresses.] Spouse [Name only] Children [Include date of birth of any child under age 18.] Children of a deceased child [Include date of birth of any child under age 18.] IF NO children or grandchildren, give name(s) and address(es) of decedent's surviving parents: Continued APPLICATION/ADMINISTRATION OR PROBATE OF WILL PC-200 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION/ ADMINISTRATION OR PROBATE OF WILL PC-200 REV. 7/12 Page 2 of 3 STATE OF CONNECTICUT RECORDED: COURT OF PROBATE [Type or print in black ink . File in duplicate.] IF NO spouse, children, grandchildren or parents, give name(s) and address(es) of decedent's brother(s) and sister(s) or children of any deceased brother or sister. IF NONE of the above apply, please refer to C.G.S. § 45a-439(a)(3) and provide a family tree. 2. BENEFICIARIES, including trustees [Give name(s) and address(es) and paragraph in Will where interest in the estate may arise. It is not necessary to list the address if it is already listed above.] 3. DECEDENT'S CONSERVATOR(S) [Give name(s) and address(es).] THE PETITIONER REPRESENTS that: Decedent left a will and codicil(s) herewith presented for probate, dated Decedent, after making said will and codicil(s), had a child born, or adopted a minor child, or married or had his or her marriage dissolved by divorce or annulment. C.G.S. §§ 45a-257a - 257c. [Explain any checked boxes on Second Sheet, PC-180. ] The proposed fiduciary named below is not the primary executor named in said will or codicil. [Explain on Second Sheet, PC-180.] Decedent left no will. One or more of the children listed are not also the children of the surviving spouse. Decedent owned an interest in real estate other than in survivorship in Connecticut at the time of death. Decedent, or spouse or children of the decedent did check appropriate box(es).] State of Connecticut did not ever receive aid or care from the State of Connecticut. [If affirmative, Department of Veterans' Affairs. C.G.S. § 45a-355. (Rocky Hill facility) The estimated value of solely-owned assets, excluding real estate is $ All the foregoing data is true and complete to the best of his or her knowledge and belief, and he or she has used all proper diligence to ascertain the names and addresses of all heirs and beneficiaries. Any additional data given on Second Sheet, PC-180, is made a part hereof. WHEREFORE, THE PETITIONER REQUESTS that said will and codicils, if any, be approved and admitted to probate and that either letters testamentary be issued or letters of administration be granted to the below-named proposed fiduciary. The representations contained herein are made under the penalties of false statement. Date: APPLICATION/ADMINISTRATION OR PROBATE OF WILL PC-200 ............................................................................... Petitioner: Continued American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION/ ADMINISTRATION OR PROBATE OF WILL PC-200 REV. 7/12 Page 3 of 3 RECORDED: STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink . File in duplicate.] PROPOSED FIDUCIARY IF APPOINTED, I WILL ACCEPT SAID POSITION OF TRUST. Signature ................................................................................................................................................................................................... [Type or print name under signature.] Address and zip code: Fiduciary is is not a resident of the State of Connecticut. Fiduciary is is not a resident of the State of Connecticut. Telephone number: Telephone number: ATTORNEY FOR PROPOSED FIDUCIARY [Name, address, zip code, telephone number, Conn. Bar Juris No.] Each of the undersigned represents that he or she has examined the application and related documents and HEREBY WAIVES NOTICE OF HEARING upon the application and has NO OBJECTION to the granting and approval thereof. [ If space is insufficient, use General Waiver, PC-181. Please also print or type name.] ........................................................... Name: ........................................................... Name: ........................................................... Name: ........................................................... Name: ........................................................... Name: ........................................................... Name: CERTIFICATE – EXISTENCE OF INTER VIVOS TRUST [Complete this section for trusts that are beneficiaries under the will.] This is to certify that the trust document for the [Name of trust] _________________________________________dated _______________ between [Name(s)] __________________________________________________________________, as grantor(s) and [Name(s)] ________________________________________________________________________as trustee(s) is in my/our possession, has been duly executed, and the trust is in full force and effect. Names and addresses of all current trustees: The representations contained herein are made under the penalties of false statement. Date: Trustee's Signature _______________________________________ [Please type or print name here.] APPLICATION/ADMINISTRATION OR PROBATE OF WILL PC-200 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL STATE OF CONNECTICUT DO NOT RECORD INFORMATION SHEET FOR PC-200, Application/ COURT OF PROBATE Administration or Probate of Will [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: ___________________________________