REQUEST FOR ORDER STATE OF CONNECTICUT RECORDED:

OF DISTRIBUTION
PC-212A REV. 7/13 Page 1 COURT OF PROBATE

[Use only with Form PC-212 when distribution is necessary.]

[Type or print in ink. File in duplicate. Use Second Sheet, PC-180, for additional data.]

TO: COURT OF PROBATE, DISTRICT NO.

ESTATE OF [Include all names and initials under which any asset was held. ] DATE OF DEATH

Hereinafter referred to as the decedent.

DECEDENT'S RESIDENCE AT TIME OF DEATH [Include full address.]

PETITIONER [Name, address and telephone number] RELATIONSHIP TO DECEDENT, if any

The amount of personal property of the decedent exceeds the listed debts and claims, and the petitioner hereby applies for an order of
distribution of the excess as follows:

The heirs-at-law of said decedent are: [Indicate any person who is a minor, under conservatorship, legal disability or in the military
service. C.G.S. §§ 45a-436. 45a-438, 45a-439.]

Spouse [Name and address]

Children [In addition to name and address, provide date of birth of any child under age 18.]

Children of a deceased child [In addition to name and address, provide date of birth of any child under age 18.]

IF NO children or grandchildren, give name and address of decedent's surviving parents:

IF NO spouse, children, grandchildren or parents, give name and address of decedent's brother(s) and sister(s) or children of any
deceased brother or sister [Identify relationship to decedent.]:

IF NONE of the above apply, please refer to C.G.S. § 45a-439(a)(3) and provide a family tree.
REQUEST FOR ORDER OF DISTRIBUTION RESET PC-212A
 REQUEST FOR STATE OF CONNECTICUT RECORDED:
ORDER OF
DISTRIBUTION COURT OF PROBATE
PC-212A REV. 7/13 Page 2 [Type or print in ink.]

One or more of the children of the decedent listed above or on Second Sheet, PC-180, is/are not also the children of the
surviving spouse.

The decedent left no will, and the petitioner requests an order of distribution to the heirs-at-law in accordance with the
laws of intestacy.

The decedent left a will dated that provides for distribution equivalent to that under the laws of intestacy, and
the petitioner, therefore, requests an order of distribution under the laws of intestacy. [If this box is checked, skip Sections A and B below.]

The decedent left a will dated , and the distribution thereunder is different from that under the laws of
intestacy, AND [If this box is checked, report the persons entitled to distribution under the will and choose either Section A or
B below.]
The persons entitled to distribution under the will are: [Give names and addresses.]

Section A. Distribution in Accordance with the Will. The heirs-at-law listed above have read the will and have signed below a
written waiver of their right to contest the will, and the petitioner requests an order of distribution stating that the excess may be
paid to the proposed persons listed above entitled to distribution of the will in accordance with the terms of the will.
The undersigned, being all of the heirs-at-law of the decedent, hereby waive their right to contest the will.
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Section B. Distribution in Accordance with the Laws of Intestacy. The persons listed above entitled to distribution under the will
have read the will and have signed below a written consent to distribution in accordance with the laws of intestacy, and the
petitioner requests an order of distribution under the laws of intestacy.
The undersigned, being beneficiaries under the will of the decedent, hereby consent to distribution in accordance with the laws of
intestate succession.
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The undersigned payor(s) of the claims listed on form PC-212 waive reimbursement.

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WHEREFORE, the undersigned petitions the court to issue an order of distribution of the excess personal property of the decedent
to the heirs-at-law and/or persons entitled to distribution under the will listed above.
The representations contained herein are made under the penalties of false statement.

Date: ...................................................................................
Petitioner:
REQUEST FOR ORDER OF DISTRIBUTION PC-212A