CONNECTICUT PROBATE COURTS Petition/Sterilization of Adult PC - 702 REV. 7/18 CONFIDENTIAL Petition /Sterilization of Adult PC - 702 Page 1 of 2 Instructions: 1) An adult person seeking sterilization, the attending physician of the person seeking sterilization, the director of the institution, if the person is institutionalized, or other interested party may use this form to request a determination of the adult person222s ability to give informed consent to sterilization, and if unable to give informed consent, a determination of whether sterilization is in the person222s best interests. 2)The petition is filed in the court for the probate district in which the adult person resides or is domiciled. 3)For more information, see C.G.S. sections 45a-690 through 45a-700.4)Type or print the form in ink. Use an additional sheet, or PC-180, Second Sheet, if more space is needed. Probate Court Name District Number In the Matter of (Name and present address) Hereinafter referred to as the respondent . Respondent222s Date of Birth Respondent222s Residen Address (if different) Respondent222s Town of Domicile Petitioner (Name and address) Guardian or Conservator of Respondent, if any (Name and address) Name and Address of Other Persons to Whom Notice Should be Given: (Identify relationships: spouse; parents; siblings, if no living parents; Disability Rights Connecticut, Inc.; and other interested parties.) THE PETITIONER REPRESENTS THAT: The attending physician has reason to believe that the respondent, an adult person, is unable to give informed consent to sterilization. The respondent is in a state school, hospital or other residential facility operated or leased by the State of Connecticut. The respondent is under conservatorship or guardianship. Sterilization is in the best interests of the respondent for the following reasons: (See C.G.S. section 45a-690 (4) for the factors considered by the court.) American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Petition/Sterilization of Adult PC - 702 REV. 7/18 CONFIDENTIAL Petition /Sterilization of Adult PC - 702 Page 2 of 2 THE PETITIONER REQUESTS THAT: The court determine whether the respondent is able to give informed consent to sterilization. If the court finds that the respondent is unable to give informed consent, the court determine that sterilization is in the best interests of the respondent. The representations made in this petition are made under the penalty of false statement. Signature of Petitioner Title Type Name Date American LegalNet, Inc. www.FormsWorkFlow.com