APPLICATION/APPOINTMENT OF TEMPORARY CONSERVATOR PC-302 REV. 7/12 Page 1 of 2 STATE OF CONNECTICUT COUR7Ғ OF PROBATE [Type or print in black ink. Complete Confidential Information Sheet for PC-302 on last page.] TO: COURT OF PROBATE, RECORDED: DISTRICT NO. IN THE MATTER OF Hereinafter referred to as the respondent, in a proceeding for involuntary representation. RESPONDENT'S RESIDENCE ADDRESS RESPONDENT'S DOMICILE ADDRESS [If different] PETITIONER [Name, address, zip code, and telephone number] RESPONDENT'S PRESENT ADDRESS [If different] RELATIONSHIP OF PETITIONER TO RESPONDENT [C.G.S. § 45a-654] PERSONS TO WHOM NOTICE SHOULD BE GIVEN: SPOUSE [If not the petitioner], CLOSEST RELATIVES [If none, so state], and INTERESTED PARTIES as defined in Probate Practice Book, Rule 3.1.02.[ Give names, addresses, zip codes, and relationships to respondent.(C.G.S. § 45a-649).] Additional data [on Second Sheet, PC-180], if any, is made a part hereof. THE PETITIONER REPRESENTS that said respondent: Is Is not domiciled in Connecticut. Is incapable of managing his/her affairs and has personal property with an estimated value of $ an estimated value of $ Is incapable of caring for himself/herself AND has has not designated a conservator as provided by C.G.S. §§ 45a-645 and 45a-650. has has not executed a living will.* has has not appointed a health care agent.[Include name and address. If unknown, so state.]* and real property with has has not appointed a health care representative. [Include name and address. If unknown, so state.]* has has not executed a power of attorney for health care decisions. [Include name and address of person appointed to act. If unknown, so state.]* is is not able to request or obtain an attorney. [C.G.S. § 45a-649.] is is not able to pay for the services of an attorney. [Submit affidavit of financial status. (C.G.S. § 45a-649).] is or is expected to become an inpatient or outpatient in a hospital, clinic, or other facility for the diagnosis, observation, or treatment of mental illness. [Note: If this box is checked, AND if consent or other authorization is being sought for (a) psychiatric medication treatment and/or (b) shock therapy, special statutory requirements must be met. The applicable forms (CM-42 or CM-46 for psychiatric medication and CM-44 for shock therapy), together with all supporting documentation, MUST be attached to this form. ALL of the documents filed in connection therewith will be recorded in a confidential volume.] *Please provide copies of these documents, if available. [Note:If Commissioner of Social Services is proposed conservator of estate and/or person, attach Affidavit, PC-310, C.G.S. § 45a-651.] APPLICATION/APPOINTMENT OF TEMPORARY CONSERVATOR PC-302 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION/APPOINTMENT OF TEMPORARY CONSERVATOR PC-302 REV. 7/12 Page 2 of 2 STATE OF CONNECTICUT COUR7Ғ OF PROBATE [Type or print in black ink.] RECORDED: Immediate and irreparable harm to the mental or physical health or financial or legal affairs of the respondent will result if a temporary conservator is not appointed. [Briefly describe reasons. Use Second Sheet, PC-180, if additional space is needed.] A report signed by the Connecticut-licensed physician who examined the respondent is attached and is part of this application. C.G.S.§ 45a-654. THE PETITIONER FURTHER REPRESENTS that the contents of this application are true to the petitioner's best knowledge and belief and requests that this court appoint the proposed temporary: Conservator of the Person Conservator of the Estate The representations contained herein are made under the penalties of false statement. Date: .................................................................................. Petitioner: PROPOSED TEMPORARY CONSERVATOR(S) If appointed, I/we will accept the position(s) of trust, as temporary conservator(s) of the: Person [Complete this section. ] Estate [Complete this section. ] Signature Signature ...................................................................... .................................................................................. Name [ Type or print ] Address: Telephone number: ATTORNEY FOR THE PETITIONER [Name, complete address, telephone number, and juris number] APPLICATION/APPOINTMENT OF TEMPORARY CONSERVATOR PC-302 ATTORNEY FOR THE RESPONDENT [Name, complete address, telephone number, and juris number] American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL STATE OF CONNECTICUT DO NOT RECORD INFORMATION SHEET FOR PC-302, Application/ COURT OF PROBATE [Type or Print in Black Ink.] Appointment of Temporary Conservator NEW 7/12 _____________________________________________________________________________________ Court of Probate, ______________________________________________ District The social security number and date of birth of the respondent are required in connection with this proceeding. In the Matter of: ______________________________________________________ , respondent. Social Security Number: ________________________________________________________________ Date of Birth: _________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com