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Application Or Temporary Administrator For Limited Pusposes Form. This is a Connecticut form and can be use in Probate Statewide.
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Tags: Application Or Temporary Administrator For Limited Pusposes, PC-207, Connecticut Statewide, Probate
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: ________________________________________________________________