Form Pc 300 – Fill Out and Use This PDF

Petition for Appointment

of ConservatorC O N N E C T I C U T P R O B A T E C O U R T S

PC-300 Rev. 10/14 Page 1 of 6

RECORDED:

RECEIVED:

Instructions:	1)	An y adult person m ay use th is form to petition for th e appoin tm en t of a con servator of an adult
		who is alleged to be in capable. A “con servator of th e person ” is appoin ted to supervise th e person al
		affairs of a person wh om th e court fin ds to be un able to m eet essen tial requirem en ts for person al
		n eeds, even with appropriate assistan ce. Th ese n eeds m ay in clude, but are n ot lim ited to, th e n eed
		for food, cloth in g, sh elter, h ealth care an d safety. A “con servator of th e estate” is appoin ted to
		supervise th e fin an cial affairs of a person wh om th e court fin ds to be in capable of doin g so to th e
		exten t th at property will be wasted un less adequate property m an agem en t is provided . Th is m ay
		in clude, but is n ot lim ited to, action s to obtain an d m an age assets, in com e an d public assistan ce
		ben efits. Th e petition m ay also request th e appoin tm en t of a successor con servator, wh o m ay act as
		con servator if th e court accepts th e resign ation of th e con servator or rem oves th e con servator or if
		th e con servator is adjudicated in capable or dies.
	2)	Th e person for wh om th e appoin tm en t of a con servatorsh ip is bein g requested is referred to as th e
		responden t .
	3) Th e petition m ust be filed in th e probate district in wh ich th e respon den t resides, is dom iciled or is
		located at th e tim e th e petition is filed .
	4) Type or prin t th e form in in k. Use an addition al sh eet if m ore space is n eeded .
Probate Court Name		District Number

Spouse (List name, address and telephone number)

Petitioner (List name, address and telephone number)		Petitioner’s Relationship to
		Respondent
Respondent’s Residence Address	Respondent’s Domicile Address	Respondent’s Present Address
	(If different)	(If different)

Other Persons to Whom Notice Should Be Given: Spouse (if not the petitioner), the Respondent’s Children, and if none, the Respondent’s Parents, and, if none, the Respondent’s Brothers and Sisters or their Representatives, and, if none, the Respondent’s Next of Kin and other Interested Parties (List names, addresses and relationships to respondent. C.G.S. section 45a-649. 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 who has been adjudicated incapable.)

Petition for Appointment of Conservator

PC-300 Page 1 of 6

Petition for Appointment

of ConservatorC O N N E C T I C U T P R O B A T E C O U R T S

PC-300 Rev. 10/14 Page 2 of 6

RECORDED:

The petitioner states that the following efforts have been made to identify or locate any party whose name and address are unknown.

THE PETITIONER FURTHER REPRESENTS that the respondent:

Has Has not been physically present in Connecticut for at least six consecutive months immediately before the filing of the petition, including any periods of temporary absence. If not, attach completed form PC-300A.

Does Does not have a conservator or guardian appointed in another state or Connecticut probate district. If “Yes,” indicate the appointing court:

There is is not a proceeding pending for the appointment of a conservator or guardian in any other state or Connecticut probate district. If “Yes,” indicate the court in which the proceeding is pending:

Has Has not designated a conservator as provided by C.G.S. section 45a-645. (Include name and address. If unknown, so state.)

If the respondent has designated a conservator, and the proposed conservator named herein is not the designated conservator, explain by separate document.

Has	Has not appointed a health care agent. (Include name and address. If unknown, so state.)*

Has Has not executed a power of attorney for health care decisions. (Include name and address of person appointed to act. If unknown, so state.)*

Has	Has not executed a durable power of attorney. (Include name and address of person appointed to act. If

unknown, so state.)*

*Please provide copies of these documents, if available.

Does	Does not own real property. C.G.S. section 45a-658. (Include address, if applicable.)

Petition for Appointment of Conservator

PC-300 Page 2 of 6

	Petition for Appointment
	of Conservator			C O N N E C T I C U T P R O B A T E C O U R T S
	PC-300 Rev. 10/14 Page 3 of 6
				RECORDE D:
	Has		Has not received public assistance or institutional care from the State of Connecticut. Conn. Gen. Statutes
	Chapter 302.
	Is		Is not receiving aid or care from the Veterans' Home and Hospital, Rocky Hill, CT. C.G.S. section 45a-649.
	Is		Is not a veteran or beneficiary receiving payment under any account from the Dept. of Veterans’ Affairs.
	C.G.S. § 45a-593.
	Does		Does not have a federal fiduciary for Veteran’s Affairs benefits. (Include name and address of person
	appointed to act. If unknown, so state.)

Is	Is not a patient in a hospital or institution. C.G.S. section 45a-649.
THE PETITIONER FURTHER REPRESENTS that said respondent:
Is	Is not in an institution for persons with psychiatric disabilities in this state. C.G.S. section 4a-17. If so, the

respondent is in such institution on the following basis:

Confined by order of a court. C.G.S. section 17a-498.

Confined under emergency certificate of a physician. C.G.S. section 17a-502.

Voluntary admission. C.G. S. section 17a-506.

Is or is expected to become an inpatient or outpatient in a hospital, clinic or other facility for the diagnosis, observation or treatment of mental illness. (Note: If this box is checked AND if consent or other authorization is being sought for

(a)psychiatric medication treatment and/or (b) shock therapy, special statutory requirements must be met. The applicable forms (CM-42 or CM-46 for psychiatric medication and PC-805 for shock therapy), together with all

supporting documentation,MUST be attached to this form. ALL of the documents filed in connection therewith will be recorded in a confidential volume.)

Is		Is not able request or obtain an attorney. C.G.S. section 45a-649.
Is		Is not able to pay for the services of an attorney. Submit Request/Order Waiver of Fees, PC-184A.

THE PETITIONER FURTHER REPRESENTS THAT:

The mental, emotional and/or physical condition that prevents the respondent from performing the necessary and proper functions for his or her well-being is as follows: (Describe briefly.)

Petition for Appointment of Conservator

PC-300 Page 3 of 6

Petition for Appointment

of ConservatorC O N N E C T I C U T P R O B A T E C O U R T S

PC-300 Rev. 10/14 Page 4 of 6

RECORDED:

If the petition is for the appointment of a CONSERVATOR OF THE ESTATE, fill in Part “A” below. If the petition is for the appointment of a CONSERVATOR OF THE PERSON, fill in Part “B.” If the petition is for BOTH conservator of the estate and conservator of the person, Parts “A” and “B” must both be completed.

A -Conservator of the Estate

The condition described above results in the respondent being unable to receive and evaluate information or make or communicate decisions to such an extent that the person is unable, even with appropriate assistance, to perform the following functions inherent in managing his or her affairs:

AND:

the respondent has property rights that will be wasted or dissipated unless adequate property management is provided.

funds are needed for the support, care or welfare of the respondent, and the respondent is unable to take the necessary steps to obtain or provide such funds.

funds are needed for the support, care or welfare of those entitled to be supported by the respondent, and the respondent is unable to take the necessary steps to obtain or provide such funds.

B -Conservator of the Person

The condition described above results in the respondent being unable to receive and evaluate information or make or communicate decisions to such an extent that the person is unable, even with appropriate assistance, to meet the following essential requirements for personal needs:

WHEREFORE THE PETITIONER REQUESTS that this court appoint the proposed conservator named below or

some other suitable person as conservator of the aforesaid respondent. (f the Commissioner of Social Services is the proposed conservator of the estate and/or person, attach Affidavit/Appointment of Commissioner of Social Services as Conservator, PC-310. C.G.S. section 45a-651.)

The petitioner also requests that the court appoint a successor conservator of the person the estate for the respondent to act in the event that the court accepts the resignation of the appointed conservator or removes the conservator or if the conservator becomes incapable or dies. P.A. 14-103 section 10.

The representations contained herein are made under the penalties of false statement.

Signature of the Petitioner___________________________

Date__________________________

Type or print name:

Petition for Appointment of Conservator

PC-300 Page 4 of 6

Petition for Appointment
of Conservator						C O N N E C T I C U T P R O B A T E C O U R T S
PC-300 Rev. 10/14 Page 5 of 6
						RECORDED:
			PROPOSED CONSERVATOR(S)
			If appointed, I will accept the position of trust.
Conservator of Person Estate				Conservator of Person Estate
Signature				Signature
Name (Type or print)
Address:

Telephone Number(s):

Telephone Number(s):

PROPOSED SUCCESSOR CONSERVATOR(S), if any

If appointed, I will accept the position of trust.

Signature			Signature
Name (Type or print)
Address:

Telephone Number(s):

Telephone Number(s):

ATTORNEY FOR PETITIONER (Name, address, telephone number and Conn. Bar Juris No.)

Signature of attorney for petitioner: __________________________________________________

(Attorney shall also file form PC-183, Appearance of Attorney.)

ATTORNEY FOR RESPONDENT (Name, address, telephone number and Conn. Bar Juris No.)

(Attorney shall also file form PC-183, Appearance of Attorney.)

EXAMINING PHYSICIAN/PSYCHOLOGIST* (Name, address and telephone number.) *Examination may be made by a psychologist for respondents with intellectual disability as defined in C.G.S. section 1-1g. C.G.S. section 45a-650, as amended.

Petition for Appointment of Conservator

PC-300 Page 5 of 6

DO NOT RECORD:

	Court of Probate,					District
	The social security number of the respondent is required in connection with this proceeding.
	In the Matter of:						, respondent.
Social Security Number:
				_________________________________

Petition for Appointment of Conservator

PC-300 Page 6 of 6