Petition/Voluntary Representation by Conservator PC-301 REV. /19 CONNECTICUT PROBATE COURTS Petition / Voluntary Representation by Conservator PC - 301 Page 1 of 4 RECEIVED: Instructions: 1) Any adult person may use this form to petition the court to appoint a voluntary conservator of the person or estate to manage his or her personal or financial affairs, or both. A voluntary 223conservator of the person224 is appointed to supervise personal affairs, such as the need for food, clothing, shelter, health care and safety. A voluntary 223conservator of the estate224 is appointed to supervise financial affairs. This may include, but is not limited to, actions to obtain and manage assets, income and public assistance benefits. The petition may also request the appointment of a successor conservator. 2)The petition must be filed in the probate district in which the petitioner resides, is domiciled or is located at the time the petition is filed. If the proposed fiduciary is not a Connecticut resident, attach a completed Appointment of Probate Judge as Agent for Service by Non-Resident Fiduciary, PC-482. 3)For more information, see C.G.S. section 45a-646.4)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 petitioner Petitioner222s Telephone Number Petitioner222s Date of Birth Petitioner222s Residence Address Petitioner222s Domicile Address (If different) Petitioner222s Present Address (If different) Spouse (Name, address and telephone number.) Other Persons to Whom Notice Should be Given, if any: (Give names, addresses and relationships to petitioner. Indicate any person who is a minor, in the military service or under conservatorship or legal disability. Include the name, address and position of trust of the legal representative of any party.) As petitioner, I represent that I have executed the following documents (check all that apply) and have provided a copy of each document: Living will. (Provide name and address of person appointed.) American LegalNet, Inc. www.FormsWorkFlow.com Petition/Voluntary Representation by Conservator PC-301 REV. /19 CONNECTICUT PROBATE COURTS In the Matter of Petition / Voluntary Representation by Conservator PC - 301 Page 2 of 4 Appointment of a health care representative. (Provide name and address of person appointed.) Appointment of a health care agent. (Provide name and address of person appointed.) Power of attorney for health care decisions. (Provide name and address of person appointed.) Power of attorney (Provide name and address of person appointed.) I further represent that I (check all that apply): Own real property located at: Am receiving or have received public assistance or institutional care from the State of Connecticut. Am receiving or have received aid or care from the Veteran222s Home and Hospital, Rocky Hill, CT. C.G.S. section 45a-649. Am a veteran or beneficiary receiving payment under an account from the Dept. of Veteran222s Affairs. C.G.S. section 45a-593. H ave a federal fiduciary for Veteran222s Affairs benefits . ( P rovide name and address of person appointed . ) Am presently under conservatorship or guardianship.(Provide name and address of conservator or guardian and name of court in which conservator or guardian was appointed.) WHEREFORE as petitioner, I request that this court appoint the proposed conservator named below or so me other suitable person as : Conservator of the estate of the petitioner to carry out the following duties and authorities: American LegalNet, Inc. www.FormsWorkFlow.com Petition/Voluntary Representation by Conservator PC-301 REV. /19 CONNECTICUT PROBATE COURTS In the Matter of Petition / Voluntary Representation by Conservator PC - 301 Page 3 of 4 Conservator of the person of the petitioner to carry out the following duties and authorities: AND THAT The conservator be required to obtain a probate bond. The conservator be excused from furnishing probate bond. The court appoint a successor conservator of the person the estate for the petitioner to act in the the event that the court accepts the resignation of the appointed conservator or removes the conservator or if the conservator becomes incapable or dies. C.G.S. section 45a-645d. The representations made in this petition are made under penalty of false statement. Signature of Petitioner Type or Print Name Date PROPOSED CONSERVATOR If appointed, I will accept the position of trust: Signature of Proposed Conservator Date Conservator of Person Estate Type or Print Name Address Telephone Number Proposed Conservator is is not a resident of the State of Connecticut. Signature of Proposed Conservator Date Conservator of Person Estate Type or Print Name Address Telephone Number Proposed Conservator is is not a resident of the State of Connecticut. American LegalNet, Inc. www.FormsWorkFlow.com Petition/Voluntary Representation by Conservator PC-301 REV. /19 CONNECTICUT PROBATE COURTS In the Matter of Petition / Voluntary Representation by Conservator PC - 301 Page 4 of 4 PROPOSED SUCCESSOR CONSERVATOR If appointed, I will accept the position of trust: Signature of Proposed Successor Conservator Date Successor Conservator of Person Estate Type or Print Name Address Telephone Number Proposed Successor Conservator is is not a resident of the State of Connecticut. Signature of Proposed Successor Conservator Date Successor Conservator of Person Estate Type or Print Name Address Telephone Number Proposed Successor Conservator is is not a resident of the State of Connecticut. American LegalNet, Inc. www.FormsWorkFlow.com