Petition/Provisional Order of Transfer of Conservatorship to Other State PC-304 REV. /19 CONNECTICUT PROBATE COURTS Petition/Provisional Order of Transfer of Conservat orship to Other State PC - 304 Page 1 of 3 RECEIVED: Instructions: 1) The conservator, conserved person, conserved person222s attorney or other interested party may file this petition to request a provisional order of transfer of an involuntary conservatorship to another state. The court will not issue a final order of transfer unless the court receives a provisional order accepting the transfer from the other state and all documents required to terminate the Connecticut conservatorship. See C.G.S. section 45a-667p. 2)If the transfer involves the termination of a lease or tenancy, sale or disposal of household furnishings,or change of residence, a Petition to Terminate Tenancy or Lease/Change Residence/Sell or Dispose of Household Furnishings of Person under Conservatorship, PC303, must also be filed. See C.G.S. section 45a-656b. 3)For more information, see C.G.S. section 45a-667 et seq.4)Type or print in ink. Use an additional sheet, or PC-180, if more space is needed. Probate Court Name District Number In the Matter of Hereinafter referred to as the conserved person Petitioner (Name, address and telephone number) Conserved Person222s Present Address Conservator of the Person (Name, address and telephone number) Conservator of the Estate (Name, address and telephone number) Court to Which Transfer of Conservatorship is Requested (Name, address and telephone number) Other Persons Entitled to Notice in the State to which Transfer of the Conservatorship is Requested (List names, addresses and relationships to conserved person.) American LegalNet, Inc. www.FormsWorkFlow.com Petition for Provisional Order of Transfer of Conservatorship to Other State PC-304 REV. /19 CONNECTICUT PROBATE COURTS In the Matter of Petition/Provisional Order of Transfer of Conservat orship to Other State PC - 304 Page 2 of 3 If the petition is for the transfer of a CONSERVATOR SHIP OF THE PERSON, complete Part A. If the petition is for the transfer of a CONSERVATORSHIP OF THE ESTATE, complete Part B. If the petition is for the transfer of BOTH conservatorship of the person and conservatorship of the estate, complete both Part A and Part B. A - Conservatorship of the Person The petitioner represents that: the conserved person is physically present in the State of ; or the conserved person is reasonably expected to move permanently to the State of AND reasonable and sufficient plans have been made for the care of, and services for, the conserved person in that state after allowing the conserved person the opportunity to participate meaningfully in decision making in accordance with the conserved person222s abilities. B - Conservatorship of the Estate The petitioner represents that: the conserved person is physically present in the State of ; or the conserved person is reasonably expected to move permanently to the State of ; or The conserved person has a significant connection to the State of , as follows: (Describe briefly.) AND adequate arrangements will be made for management of the conserved person222s property in that state. The transfer involves the termination of a tenancy or lease of the conserved person, the sale or disposal of real property or household furnishings of the conserved person, or a change in the conserved person222s residence or the placement of the conserved person in an institution for long-term care. See C.G.S. section 45a-656b. The petitioner further represents that the State of will accept the transfer of the the conservatorship of the person the conservatorship of the estate American LegalNet, Inc. www.FormsWorkFlow.com Petition for Provisional Order of Transfer of Conservatorship to Other State PC-304 REV. /19 CONNECTICUT PROBATE COURTS In the Matter of Petition/Provisional Order of Transfer of Conservat orship to Other State PC - 304 Page 3 of 3 WHEREFORE, the petitioner requests that this court issue a provisional order of transfer of the conservatorship to the State of as set forth above. The representations made in this petition are made under penalty of false statement. Signature of Petitioner Type or Print Name Date American LegalNet, Inc. www.FormsWorkFlow.com