Petition/Estate Examiner for Limited Purpose PC-207 REV. 4/17 RECEIVED: CONNECTICUT PROBATE COURTS Instructions: 1) A person interested in an estate of a deceased person may use this form to request authority: a) to obtain financial information for the limited purpose of determining whether the estate may be settled as a small estate under C.G.S. section 45a-273; b) to obtain medical and/or financial information 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 or a potential claim for benefits under a worker's compensation act, an insurance policy or other benefits in favor of the estate, surviving spouse, children, heirs or other dependents of the deceased person. An estate examiner appointed by the court has access to information but has no authority over the assets of the deceased person. 2) The petition, with the copy of the death certificate and the confidential information sheet, should be filed in the court for the probate district having jurisdiction over the estate of the deceased. 3) For more information, see C.G.S. sections 45a-317a. 4) Type or print the form in ink. Use a separate sheet, or PC-180, if more space is needed. District Number Date of Death Date of Petition Probate Court Name Estate of Petitioner (List name, address and telephone number.) Petitioner's relationship to deceased person List Names and Addresses of Each Heir and Other Dependents of the Deceased Person. (Indicate any person who is under conservatorship, legal disability or in the military service. C.G.S. sections 45a-436, 45a-438, 45a-439.) Spouse: Children:(Include date of birth of any child under the age of 18.) Children of a deceased child:(Include date of birth of any child under the age of 18.) The decedent's surviving parents (if no children or grandchildren): The decedent's brothers and sister(s) (if no spouse, children, grandchildren or parents): Petition/Estate Examiner for Limited Purpose PC-207 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Petition/Estate Examiner for Limited Purpose PC-207 REV. 4/17 Other dependents of the decedent: CONNECTICUT PROBATE COURTS THE PETITIONER REPRESENTS THAT: He or she is a person interested in the estate of the deceased and: Has a need to obtain financial information concerning the deceased person for the limited purpose of determining whether the estate may be settled as a small estate under C.G.S. section 45a-273. Identify any financial institutions in which the decedent may have had assets: financial medical information concerning the deceased person for the limited purpose Has a need to obtain of investigating a potential cause of action of the estate, surviving spouse, children, heirs or other dependents of the deceased person. Provide the nature of the cause of action and the type and location of the financial and/or medical information sought: Has a need to obtain financial medical information concerning the deceased person for the limited purpose of investigating a potential claim for the 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. Provide the nature of the claim and the location of the financial and/or medical information sought: THE PETITIONER REQUESTS THAT the court appoint an estate examiner for the limited purpose stated above. The representations made in this petition are made under penalty of false statement. Signature of Petitioner Proposed Estate Examiner If appointed, I will accept the position of estate examiner for the limited purposes set forth above. I FURTHER ACKNOWLEDGE THAT IF APPOINTED, I WILL HAVE NO AUTHORITY OVER ASSETS OF THE DECEASED PERSON. Signature Type or Print Name Address Telephone Number Date Each of the undersigned represents that he or she has examined the petition and WAIVES NOTICE OF HEARING on the petition and has NO OBJECTION to the granting and approval of the petition. (If space is insufficient, use General Waiver, PC-181.) Signature Type or Print Name Signature Signature Petition/Estate Examiner for Limited Purpose Type or Print Name Type or Print Name PC-207 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL INFORMATION/ Petition/Estate Examiner for Limited Purposes PC-207C NEW 10/16 CONNECTICUT PROBATE COURTS FOR COURT USE ONLY The social security number of the decedent is required in connection with this proceeding. In the Matter of: ____________________________________________________. deceased Social Security Number: _______________________________ Confidential Information/Petition Estate Examiner for Limited Purposes PC-207C American LegalNet, Inc. www.FormsWorkFlow.com