APPLICATION/DECREE AND RETURN -- SAFE DEPOSIT BOX PC-203 REV. 10//08 RECORDED: STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink. File in duplicate.] DISTRICT NO. TO: COURT OF PROBATE, DISTRICT OF IN THE MATTER OF TOWN OF DOMICILE OF DECEDENT ,DECEASED PETITIONER[Name, address, zip code, and telephone number] RELATIONSHIP TO DECEDENT The petitioner represents that said decedent died a resident of this probate district and that there may be a safe deposit box in the sole name of the decedent in the following bank: [Give name, address, and zip code, and branch where safe deposit box is located.] Wherefore, the petitioner, being the spouse, next of kin, or a person having an interest in the presence of a will or cemetery deed, hereby requests that the Court issue an order to open the decedent's safe deposit box in the presence of an officer of said bank for the purpose of removing the will or cemetery deed from such box. The representations contained herein are made under the penalties of false statement. Date: ...................................................................................... Petitioner: TO: COURT OF PROBATE, DISTRICT OF DISTRICT NO. ESTATE OF LATE OF ,DECEASED PRESIDING JUDGE: The foregoing application having been presented to this Court, the Court finds that notice should be and is hereby dispensed with for cause shown and to grant said petition is proper. After hearing held, it is ORDERED AND DECREED that the above-named petitioner be permitted to enter the decedent's safe deposit box in the presence of an officer of said bank for the purposes stated in the above application. And it is FURTHER ORDERED that the officer of said bank make DUE RETURN to this Court that only the will or cemetery deed was removed from said safe deposit box OR that there was no such will or cemetery deed in the safe deposit box and that nothing was removed. It is FURTHER ORDERED that an inventory be made of the contents of said safe deposit box by the petitioner in the presence of an officer of said bank. The petitioner shall forthwith DELIVER to this Court any will found in such safe deposit box together with the inventory of the contents of such safe deposit box, if such inventory was directed by this Court. Dated at: ,Connecticut, on [Month, Day, Year] BY ORDER OF THE COURT ...................................................................................................................... Judge Court Seal Attested to be a true copy of said application and order of said Court. Clerk Ass't Clerk ..................................................................................................................... Judge Clerk Ass't Clerk DISTRICT NO. COURT OF PROBATE, DISTRICT OF The undersigned, a duly authorized officer of the bank referred to in the above application and order, hereby makes return in compliance with said order that: only the will or cemetery deed was removed from the decedent's safe deposit box. there was no will or cemetery deed in the decedent's safe deposit box, and nothing was removed. SIGNED ................................................................................................... Print Name of Officer: APPLICATION/DECREE AND RETURN -- SAFE DEPOSIT BOX PC-203 American LegalNet, Inc. www.FormsWorkflow.com