Pc212 Form – Fill Out and Use This PDF

	Affidavit in Lieu of Probate	C O N N E C T I C U T P R O B A T E C O U R T S
	of Will/ Administration
	PC-212 REV. 10/17
	R E C E I V E D :

Instructions:	1) This form may be used to settle a decedent’s estate using the small estates procedure under C.G.S.
	section 45a-273. The small estates procedure may be used only if both of the following conditions
	are met: (a) the decedent had no solely owned real estate and (b) the total value of all of the
	decedent’s personal property does not exceed $40,000.

2)The small estates procedure is a simplified method of settling an estate that avoids formal probate proceedings. Under the procedure, the decedent’s assets may be used to: (a) pay the decedent’s funeral expenses and the expenses of administering the estate (these are referred to as expenses), pay claims associated with the decedent’s last illness or other claims that the decedent owed at the time of death (these are referred to as claims) or (b) reimburse a person who paid expenses or claims from nonprobate assets. Any assets remaining after payment of expenses and claims are then distributed to the decedent’s heirs or beneficiaries.

3)Attach PC-212A, Request for Order of Distribution, if (a) assets exceed expenses and claims or (b) a person who paid expenses or claims with nonprobate assets waives reimbursement.

4)For further information, see C.G.S. sections 45a-273, 45a-365, 17b-95 and 18-85b and Probate Court Rules of Procedure, section 30.12.

5)Type or print the form in ink. Use Second Sheet, PC-180, or an additional sheet, if more space is needed. File two copies of the form with the Probate Court where the decedent resided.

Probate Court NameDistrict Number

Estate of (Include all names and initials under which assets were held by the decedent.) Date of Death

Decedent’s Residence at Time of Death (Include full address.)

Petitioner (Name, address and telephone number.)	Relationship to Decedent, if any
___________________________________________________________________________________________________________
THE PETITIONER represents that:
The petitioner is the surviving spouse of the decedent.

There is no surviving spouse, and the petitioner is a next of kin of the decedent.

There is no surviving spouse or next of kin, or such surviving spouse or next of kin has refused to file such affidavit, and the petitioner has the following interest in the estate:

No petition for settlement of the estate is pending in any Probate Court.

The decedent died owning no real estate, other than survivorship real estate, if any, in the State of Connecticut. The market value of the solely owned assets listed below does not exceed $40,000.

The decedent

did

did not ever receive aid or care from the State of Connecticut.

Affidavit In Lieu of Probate of Will/Administration

PC-212 Page 1 of 3

	Affidavit in Lieu of Probate	C O N N E C T I C U T P R O B A T E C O U R T S
	of Will/ Administration
	PC-212 REV. 10/17

The decedent left a will dated _______________________________, which is not being presented for probate.

The decedent left no will.

_________________________________________________________________________________________________

Assets

The decedent died owning the following solely owned assets: (List specific account or vehicle identification (VIN) numbers.)

Description

Fair Market Value

Total $

________________________________________________________________________________________________

Expenses and Claims

The expenses and claims are as follows:

Creditor	Amount (If already paid, state
	name of person who paid.)

Funeral Expenses

Administration Expenses

(For example, probate fees and attorney's fees.)

Claims due for Last Sickness

Taxes due State of Connecticut or the United States

Other Claims

Affidavit In Lieu of Probate of Will/Administration

PC-212 Page 2 of 3

Affidavit in Lieu of Probate
of Will/ Administration	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-212 REV. 10/17

The funeral director has not been paid, and the petitioner requests that the court order payment from the assets listed above by: (a) direct transfer or (b) sale of assets.

The following creditors have not been paid, and the petitioner requests that the court order payment from the assets listed above by: (a) direct transfer or (b) sale of assets:

The expenses, claims and taxes listed above have been paid in the manner prescribed by C.G.S. section

45a-365 or, if the decedent received aid or care from the state of Connecticut or is obligated to pay the costs of incarceration, in the manner prescribed by C.G.S. sections 17b-95 or 18-85b, respectively.

Assets exceed expenses and claims, and form PC-212A is attached.

One or more of the children listed on PC-212A is/are not also children of the surviving spouse.

WHEREFORE, the petitioner requests the court to authorize the transfer of the assets listed above and/or the sale of the assets and payment of the proceeds, as indicated above.

The representations made in this affidavit are made under the penalty of false statement.

Signature of Petitioner_____________________________

Date_____________________________

Affidavit In Lieu of Probate of Will/Administration

PC-212 Page 3 of 3

	CONFIDENTIAL INFORMATION/
	Petition/Affidavit in Lieu of Probate of Will/	C O N N E C T I C U T P R O B A T E C O U R T S
	Administration
	PC-212CI REV. 10/17
		FOR COURT USE ONLY
	RECEIVED:

Probate Court Name		District Number
In the Matter of		, deceased

The social security number of the decedent named above is required in connection with this proceeding.

Social Security Number _______________________________________________________________________

Confidential Information/Affidavit In Lieu of Probate of Will/Administration

PC-212CI