CONNECTICUT PROBATE COURTS Landlord222s Affidavit Under C.G.S. section 47a - 11d Re: Possessions of a Deceased Tenant PC - 2106 NEW 1/18 Landlord222s Affidavit Under C.G.S. section 47a- 11d Re: Possessions of a Deceased Tenant PC - 2106 RECEIVED : Instructions: 1) A landlord may use this form to file an affidavit in the Probate Court when a sole unit subject to a monthly lease or a lease for a term has died, and the landlord has complied with any provisions of the lease permitting termination of the lease upon the death of the tenant. 2)The petition should be filed in the court for the probate district having jurisdiction over the estate of thedeceased occupant. 3)For more information, see C.G.S. sectionProbate Court Name District Number In the Matter of (Name and address.) Hereinafter referred to as the deceased occupant. Deceased Occupant222s Date of Death Landlord (Name, address and telephone number.) Name and Address of Emergency Contact, if any The deceased occupant did not designate an emergency contact. Name and Address of the Deceased Occupant222s Next of Kin The next of kin are unknown. Terms of the lease THE LANDLORD REPRESENTS THAT: 1)The deceased was the sole occupant of a dwelling unit subject to a monthly lease or lease for a term, and thelandlord has complied with any provisions of the lease permitting termination upon the death of the occupant.Signature of Landlord Date American LegalNet, Inc. www.FormsWorkFlow.com