Fill and Sign the Connecticut Small Estate Affidavit in Lieu of Administration Form

Affidavit In Lieu of Probate of Will/Administration PC-212 Page 1 of 3 Affi dav it in Lieu of Probate CONNECTICUT PROBA TE COURTS of Will/ Administration PC -212 R EV. 10 /17 RECEIVED: Instructions: 1)This form may be use d 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. section s 45a -273 , 45a -365, 17b -95 and 18 -85b and Probate Cou rt 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 Name District 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 PETIT I ONER 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 spous e 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 decede nt died owning no real estat e, other than survivorsh ip real estate, if any, in the State of Connecticut. The market value of the solely owned assets listed below does not exceed $40,000. Th e decedent did di d not ever receive aid or care f rom the S tate of Connecticut. Affidavit In Lieu of Probate of Will/Administration PC-212 Page 2 of 3 Affi dav it in Lieu of Probate CONNECTICUT PROBATE COURTS of Will/ Administration PC -212 R EV. 10 /17 The decedent left a will dated _______________________________, which is not being presented for probate. The decedent left no will. _________________________________________________________________________________________________ Asse ts The decedent died owning the following solely owned assets: (List specific account or vehicle identification (VIN) number s.) Description Fair Market Value T otal $ ________________________________________________________________________________________________ Expenses and Claims The expenses and claims are as follows: Cre ditor 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 3 of 3 Affidav it in Lieu of Probate CONNECTICUT PROBATE COURTS of Will/ Administration PC -212 R EV. 10 /17 The funer al director has not been paid, and the petitioner reTuests that the court order payment from the assets listed above by: a direct transfer or b sale of assets. The folloZinJ creditors have not been paid, and the petitioner reTuests 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-3 65 or, if the decedent received aid or c are from t he state of C onnecticut or is obligat ed to pay the costs of i ncarceration, in the manner pr escribed by C.G.S. sections 17b-95 or 1 8-85b, r espectively. 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 r epresentations made in this affidavit are made under the penalt y of false statement. Signat ure of Petitioner_____________________________ Date_____________________________ Confidential Information/Affidavit In Lieu of Probate of W ill/Administration PC-212CI CONNECTICUT PROBATE COURTS CONFIDENTIAL INFORMATION/ Petition/Affidavit in Lieu of Probate of Will/ Administration PC -212C I REV. 10/1 7 FOR COURT USE ONLY RECEIVED: Probate Court Name District Number In the Matter of , deceased The soc ial security number of the decedent named above is required in connection with this proceeding. Soci al Security Number _______________________________________________________________________