APPLICATION/TEMPORARY STATE OF CONNECTICUT RECORDED: ADMINISTRATION FOR LIMITED COURT OF PROBATE PURPOSES (C.G.S. § 45a-316, as amended) PC-207 REV. 7/12 Page 1 of 2 [Type or print in black ink. File in duplicate.] [Complete Confidential Information Sheet for PC-207 on last page. Use Second Sheet, PC-180, for additional data.] TO: COURT OF PROBATE, d dd DISTRICT NO. ESTATE OF [Include all names and initials under which any asset was held.] DATE OF DEATH DECEDENT'S RESIDENCE AT TIME OF DEATH [Include full address.] DATE OF APPLICATION 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, zip code and telephone number] SURVIVING SPOUSE [Name, address, and zip code. If there is no surviving spouse, so state.] HEIRS, CHILDREN AND OTHER DEPENDENTS OF THE DECEDENT. Indicate any person who is under conservatorship, legal 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: 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. APPLICATION/TEMPORARY ADMINISTRATION FOR LIMITED PURPOSES PC-207 APPLICATION/TEMPORARY ADMINISTRATION FOR LIMITED PURPOSES (C.G.S. § 45a-316, as amended) PC-207 REV. 7/12 Page 2 of 2 STATE OF CONNECTICUT RECORDED: COURT OF PROBATE [Type or print in black ink. File in duplicate.] 2. OTHER DEPENDENTS OF THE DECEDENT [Give name(s) and address(es).] THE PETITIONER REPRESENTS that: He or she is a person interested in the estate named above and has a need to obtain financial medical information concerning the deceased person for the limited purpose of investigating a potential cause of action of the estate, surviving spouse, children, heirs, or other dependents of the deceased person. He or she is a person interested in the estate named above and has a need to obtain financial medical information concerning the deceased person for the limited purpose of investigating a potential claim for benefits under a workers' compensation act, an insurance policy or other benefits in favor of the estate, surviving spouse, children, heirs or other dependents of the deceased person. Please explain the purpose for the application. [Use Second Sheet, PC-180, if additional space is needed.] Any additional data given on Second Sheet, PC-180 is made a part hereof. WHEREFORE,THE PETITIONER REQUESTS the appointment of a temporary administrator for the limited purpose stated above. The representations contained herein are made under the penalties of false statement. Date: ................................................................................ Petitioner: PROPOSED TEMPORARY ADMINISTRATOR If appointed, I will accept said position of temporary administrator for the limited purposes set forth above. I FURTHER ACKNOWLEDGE THAT IF APPOINTED I WILL HAVE NO AUTHORITY OVER THE ASSETS OF THE DECEASED PERSON. Signature ................................................................................................... ............................................................................... [Type or print name under signature. ] Address and zip code: Telephone Number: Telephone number: Each of the undersigned represents that he or she has examined the application and related documents and HEREBY WAIVES NOTICE OF HEARING upon said 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.] ........................................................... ........................................................... APPLICATION/TEMPORARY ADMINISTRATION FOR LIMITED PURPOSES PC-207 ....................................................... CONFIDENTIAL DO NOT RECORD STATE OF CONNECTICUT INFORMATION SHEET FOR PC-207, Application/ COURT OF PROBATE [Type or Print in Black Ink.] Temporary Administration For Limited Purposes NEW 7/12 _____________________________________________________________________________________ Probate Court, District of: ______________________________________________ The social security number of the decedent is required in connection with this proceeding. In the Matter of: ______________________________________________________, deceased Social Security Number: ________________________________________________________________