APPLICATION FOR VOLUNTARY REPRESENTATION BY CONSERVATOR PC-301 REV. 10/11 Page 1 of 2 RECORDED: STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink.] TO: COURT OF PROBATE, DISTRICT NO. IN THE MATTER OF [Name, address, zip code, and telephone number.] Hereinafter referred to as the petitioner. DATE OF BIRTH SPOUSE [Name, address, zip code, and telephone number] SOCIAL SECURITY NO. PERSONS TO WHOM NOTICE SHOULD BE GIVEN: SPOUSE, 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 petitioner.] C.G.S. §45a-646. [To give further details, use Second Sheet, PC-180.] THE PETITIONER REPRESENTS that he/she: Is now living at the present address written above and has domicile in the town written above. Has not executed a living will.* Has Has Has not appointed a health care representative. [Include name and address. If unknown, so state.]* Has Has not appointed a health care agent. [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.]* Does Does not own real property. C.G.S. §45a-658. Has Has not received public assistance or institutional care from the State of Connecticut. Conn. Gen. Statutes Chapter 302. Is Is not a veteran or beneficiary receiving payments under any account from the Veterans' Administration. C.G.S. §45a-593. Is Is not a patient of the Veterans' Home and Hospital, Rocky Hill, CT C.G.S. §45a-649. Is not presently under conservatorship. Is THE PETITIONER FURTHER REPRESENTS that the spouse and closest relatives, if any, of said petitioner are as written above. WHEREFORE, THE PETITIONER REQUESTS that this Court appoint the proposed conservator named below or some other suitable person as: Conservator of the estate of said petitioner to carry out the following duties and authorities: *Please provide copies of these documents, if available. APPLICATION FOR VOLUNTARY REPRESENTATION BY CONSERVATOR PC-301 Page 1 of 2 Continued American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR VOLUNTARY REPRESENTATION BY CONSERVATOR PC-301 REV. 10/11 Page 2 of 2 STATE OF CONNECTICUT RECORDED: COURT OF PROBATE Conservator of the person of said petitioner to carry out the following duties and authorities: AND THAT probate bond of the conservator with suitable surety be fixed at $ the conservator be excused from furnishing probate bond. The representations contained herein are made under the penalties of false statement. Date: Petitioner: ....................................................................................... PROPOSED CONSERVATOR(S) If appointed, I will accept said position of trust. Signature ....................................................................................... Signature ....................................................................................... Name [Type or print] Address: Telephone Number(s): Telephone Number(s): ATTORNEY FOR PETITIONER [Name, address, zip code, telephone number, and juris number.] APPLICATION FOR VOLUNTARY REPRESENTATION BY CONSERVATOR PC-301 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com