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Connecticut ______ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -5- __________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identification. ___________________________: ___________________________________ State of __________________________ ) ) ss County of ________________________ ) The foregoing instrument was acknowledged before me this _____ day of ______________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ___________________________________ City: __________________________________ State_______ (state). ________________________________ Signature of Principal Witness Signature: ___________________________________ Name: ___________________________________ City: ______________________is Power of Attorney. I may revoke this Power of Attorney at any time by providing written notice to my Agent. Signed on ________________ (date), at _______________________ (city), ___________________ting from judgment errors made in good faith. However, Agent will be liable for breach of fiduciary duty, failure to act in good faith and/or willful misconduct, while acting under the authority of thed by operation of law, any person relying in good faith on the authority of this document, without notice of such termination, shall be held harmless. -4- Agent shall not be liable for losses resule of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of reliance on this power of attorney. If this General Power of Attorney is terminatt by my Agent. Any third party who receives a copy of this document may act under it. Revocation of the power of attorney is not effective as to a third party until the third party has actual knowledgy Agent; (b) my Agent to have any rights or ownership with respect to any life insurance policies I may own on the life of my Agent; and/or (c) my assets to be subject to a general power of appointmensition of any proceeds paid to my Agent based on this document. The powers granted to my Agent by this power-of-attorney are limited to the extent necessary to prevent (a) my income to be taxable to mll still remain in full force and effect and not be affected by any partial invalidity. No person needs to inquire as to the reasons for the use or issuance of this power-ofattorney or as to the disposcope of powers granted herein in any manner. If any part of this document is held to be invalid, illegal or unenforceable under applicable law, then the remaining unaffected parts of the document sha Agent. This Power of Attorney shall be construed broadly as a General Power of Attorney. The listing of specific terms, rights, acts or powers are not intended to restrict or limit the definition or s my Agent If so requested by myself or any authorized personal representative or fiduciary acting on my behalf, my Agent shall provide an accounting for all funds handled and all acts performed as myall reasonable expenses incurred as a result of carrying out any provision of this Power of Attorney. If desired, my Agent shall also be entitled to reasonable compensation for any services provided aack of capacity to receive and evaluate information effectively, to communicate decisions, and/or to manage my financial resources and affairs properly. My Agent shall be entitled to reimbursement of , and -3- authority of this document shall remain in full force and effect thereafter until my death or until my disability or incapacity. As used herein, "disability" or "incapacity" shall mean a ly Agent or my Agent's estate. This General Power of Attorney and the rights, powers, and authority of my Agent shall become effective immediately upon execution of this instrument. The rights, powersstate, trust, or other entity, as may be appropriate. However, Agent may not disclaim assets, to which I would be entitled, if the result is that the disclaimed assets pass directly or indirectly to mif such trust exists at the time of such transfer. 17. To disclaim any interest (subject to other provisions of this document), which might be transferred or distributed to me from any other person, e obligations of support which my Agent may owe to others, excluding those whom I am legally obligated to support. 16. To transfer any of my assets to the trustee of any revocable trust created by me, y hold in favor of my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, or (c) use any of my assets to discharge any of my Agent's legal obligations, including any any of my assets, interests or rights, directly or indirectly, to my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, (b) exercise any powers of appointment I mannual right shall be non-cumulative and shall lapse at the end of each calendar year. However, my Agent may not, unless specifically authorized by this document, (a) gift, appoint, assign or designategifts made shall be limited to gifts that qualify for the federal gift tax annual exclusion, shall not exceed in value the federal gift tax annual exclusion amount in any one calendar year, and this aocuments. Gifts to minors may be made to the minor directly or parent, guardian or close friend of the minor or pursuant to the Uniform Gifts to Minors Act or the Uniform Transfers To Minors Act. Any le property, to such persons or organizations without regard to whether such gifts are a part of my estate planning or otherwise, and if necessary, to file any state and federal gift tax returns and drnmental agencies, relating to tax matters and to negotiate, compromise or settle any matter with such agency. 15. To make gifts and charitable contributions of my real, personal, tangible or intangibdy, including, but not limited to, federal, state, local or other income and tax returns and necessary and/or related documents; to obtain or provide information to and from any agency, including gove accountants, investment professionals, brokers and real estate agents. 14. To prepare, or cause to be prepared, sign, and/or file any documents with any federal, state, local or other governmental boy own or have an interest in or may own or have an interest in, in the future. 13. To employ any professional and/or business assistance as may be appropriate, including but not limited to, attorneys, any and all rights, including proxy rights, with respect to stocks, bonds, debentures, commodities, options or any other investments. -2- 12. To maintain and/or operate any business that I currentlstorage area owned or leased by me alone or in conjunction with any other person, including access to their contents, and to examine, remove, keep or otherwise dispose of the contents. 11. To exercisery to deposit, negotiate, sell or transfer any note, security, or draft of the United States of America, including U.S. Treasury Securities. 10. To have access to any safe deposit box, vault or other ank statements, passbooks, drafts, warrants, money orders, certificates, cashier checks, cash or vouchers payable to me by any person, firm, corporation or political entity; to perform any act necessanking or financial institution with respect to any of my accounts, including, but not limited to, making deposits and withdrawals, negotiating or endorsing any checks or other instruments, obtaining bavings accounts, certificates of deposit, investment accounts, brokerage accounts, retirement plan accounts, and other similar accounts with financial institutions; to conduct any business with any bay Agent, to act as my "Representative Payee" for the purpose of receiving Social Security benefits. 9. To open, maintain and/or close bank accounts, including, but not limited to, checking accounts, sle request by any government or its agencies in connection with governmental benefits (including but not limited to, medical, military and social security benefits), and to appoint anyone, including ms, retirement plans, insurance benefits and government program including, but not limited to, Social Security and Medicare; to prepare applications, provide information, and perform any other reasonabnd to make any elections and disclaimers under such policies. 8. To receive, deposit, hold, demand, deal with and/or sue to recover all payments I receive from any annuity, pension, retirement benefitansaction. 7. To apply for, purchase, maintain and/or deal with insurance and annuity contracts, insurance policies, including life insurance upon my life or the life of any other appropriate person aure; the right to remove tenants and to recover possession; and the right to ask for, demand, sue for, collect, recover and receive all monies which may become due and owing to me by reason of such trred in the future by me) and to execute any necessary document, instrument or deed for such transactions. This includes the right to sell or encumber any homestead that I now own or may own in the futr manner (on such terms and at prices my Agent may deem proper) deal with all, any part or any interest in any real or personal property or asset whatsoever, tangible or intangible (now owned or acqui, me or in which I have or may hereafter acquire any interest, to have, or use. 6. To maintain, manage, insure, lease, rent, sell, mortgage, improve, repair, exchange, invest, reinvest and in any otheidends, certificates of deposit, any and all documents of title and demands whatsoever, whether agreed to or disputed, now due or due -1- in the future, owned by, due, owing payable, or belonging to or entity. 5. To receive, hold, possess and/or invest any and all sums of money, accounts, debts, bonds, commercial papers, checks, drafts, causes of action, bequests, deposits, notes, interests, divtake any and all legal steps necessary to recover and collect any amount or debt owed to me. 4. To adjust, compromise and settle any claim, against me or asserted on my behalf against any other personion of mortgages, lien, judgments, security agreements and other debts and obligations and such other instruments in writing of whatever kind and nature as may be. 3. To request, ask, demand, sue and s, certificates of deposit of, or investments with or through banks, savings and loan, brokers, mutual fund companies or other institutions, proofs of loss, evidences of debts, releases, and satisfactments, leases, mortgages, notes, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock certificates, proxies, warrants, commercial papers, withdrawal and deposit slipy such contract and/or agreement, including but not limited to applications, assignments, bills of sale or lading, bonds, contracts, covenants, conveyances, deeds, options, trust deeds, security agree of whatever kind or nature, on my behalf and in my name. 2. To enter into binding contracts on my behalf and to sign, endorse and execute any written agreement and document necessary to enter into anvirtue of this power of attorney and the rights hereby granted. My Agent's powers and authority shall include, but not be limited to: 1. To conduct, engage in, and transact any and all lawful businessngible, or matter whatsoever as I could do if personally present. I hereby ratify and confirm all acts that my Agent, or my Agent's substitute or substitutes, shall lawfully do or cause to be done by legal right or obligation whatsoever that I now have or may later acquire in connection with or relating to any person, item, transaction, thing, business, property, real or personal, tangible or inta____________________________________________ my true and lawful attorney-in-fact for me and in my name, and in my behalf. My Agent shall have full power and authority to perform any act, power, duty, Principal") maintaining an address at _______________________________________________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: _________ppointment, the agent assumes the fiduciary and other legal responsibilities of an agent. -3- GENERAL POWER OF ATTORNEY KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("document does not authorize anyone to make medical and other health-care decisions for you. You may revoke this power of attorney if you later wish to do so. AGENT: By accepting or acting under the ach action undertaken by your agent, within the scope of this power of attorney document, is legally binding upon you. If you have any questions about these powers, obtain competent legal advice. This . You ("principal") are providing another person ("agent") with the power to handle business and legal matters on your behalf, including the power to sell, mortgage or dispose of your property. Any sully include state specific instructions. -2- CAUTION! PRINCIPAL: The Powers granted by this power of attorney document are broad and sweeping. Before signing this document, consider its consequencestute for legal advice. Furthermore, this information is general information that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generatorneys (available at findlegalforms.com as well), stays in effect even if the Grantor later becomes disabled or incapacitated. Please note that this information is not intended as and is not a substiif necessary. Although, some states don't require that a General Power of Attorney be witnessed, it is always a very good idea to do so. Another type of Power of Attorney, called a Durable Power of Atoperty. Notarization will make it more difficult for any third party to challenge the validity of the Power of Attorney and will allow the General Power of Attorney to be recorded as a public record, revoke a General Power of Attorney at any time. A General Power of Attorney should always be notarized, even if your state does not require it, especially if the Agent will be dealing with any real prpowerful" instrument and should be granted with care. Any action undertaken by the Agent, within the scope of the Power of Attorney document, will be legally binding upon the Grantor. The Grantor can ney-In-Fact for the Principal does not need to be a lawyer. Almost anyone can be appointed an Attorney-In-Fact by a power of attorney. The Agent should be a competent adult. A Power of Attorney is a "remains effective until the death of the Grantor or until the Grantor becomes disabled or incapacitated. Note that the word "attorney" is not used here to mean "lawyer". The person acting as the Attornt person (called the "Principal" or "Grantor") to authorize someone else (called the "Agent" or "Attorney-InFact") to act on his or her behalf. This particular Form becomes effective immediately and se of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -1- Information General Power of Attorney A General Power of Attorney allows a natural "mentally" competebe a starting point for you and should not be used without consulting with an attorney first. An Attorney should be consulted before negotiating any document with another party. [_] The purchase and uweeping, as the Agent has the power to handle business and legal matters on the Principal's behalf. [_] These forms are not intended and are not a substitute for legal advice. These forms should only e Agent (or attorney-in-fact) as to the tasks the Agent should complete. The Grantor should also be very careful in the selection of the Agent. The powers granted by this document are very broad and sitnesses. [_] The Principal should keep the original document, as well as a copy. The Agent should have access to the original document as needed. [_] The Principal should be careful in instructing tha public record, if necessary. [_] Two witnesses need to sign the Power of Attorney. The witnesses should be competent adults. The Agent, the Agent's spouse or children, and the Notary should not be wncipal (i.e. the person granting the Power of Attorney; sometimes called the Grantor) should sign the document before a Notary. Notarization will allow the General Power of Attorney to be recorded as er of Attorney [_] This General Power of Attorney becomes effective immediately and remains effective until the death of the Grantor or until the Grantor becomes disabled or incapacitated. [_] The PriInstructions & Checklist General Power of Attorney [_] This package contains (1) Instructions & Checklist for General Power of Attorney; (2) Information for General Power of Attorney; (3) General Pow ConnecticutConnecticut ved Will Affidavit _______________________ , and ___________________________________ witnesses, this _______ day of __________________, 20____. __________________________________________ Notary public [SEAL] Self-proed, sworn, and acknowledged before me ________________________________ a notary public, and by _________________________________________, the testator, and by ___________________________________ , _________________________________________ _____________________________________________ (Witness) Print Name: ___________________________________ Address: ______________________________________ Subscribe: ___________________________________ Address: ______________________________________ _____________________________________________ (Witness) Print Name: ___________________________________ Address: each witness is over 18 years of age and otherwise competent to be a witness. _____________________________________________ (Testator) _____________________________________________ (Witness) Print Nam signed the will as witness, and that to the best of the witness's knowledge the testator was at that time 18 years of age or older, of sound mind, and under no constraint or undue influence and that ign for the testator), that the testator executed it as the testator's free and voluntary act for the purposes expressed in it, that each of the witnesses, in the presence and hearing of the testator,o the undersigned authority under penalty of perjury that the testator signed and executed the instrument as the testator's will, that the testator signed willingly (or willingly directed another to switnesses, respectively, whose names are signed to the attached or foregoing instrument in those capacities, personally appearing before the undersigned authority and being first duly sworn, declare t OF ________________________ We, ________________________________, and _______________________________, and ________________________________ and ________________________________, the testator and the ____________________ Initials: __________ Testator __________ Witness __________ Witness __________ Witness Page 7 of ______ Self-Proved Will Affidavit STATE OF __________________________ COUNTY____ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ _______________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ _______________________________ture: Name: Address: City: State: Witness Signature: Name: Address: City: State: ___________________________________ ___________________________________ ___________________________________ ___________w age 18 or older, is a competent witness, and resides at the address set forth after his or her name. Dated: ____________________, ______ Witness Signature: Name: Address: City: State: Witness Signaestator's Will; We believe the maker is of sound mind and memory; We believe that this Will was not procured by duress, menace, fraud or undue influence; The maker is age 18 or older. Each of us is noreby subscribe our names as witnesses on the date shown above. Initials: __________ Testator __________ Witness __________ Witness __________ Witness Page 6 of ______ We understand this is the Tnstrument to be his/her Last Will and Testament and we, at the Testator's request and in the Testator's sight and presence and at Testator's request, and in the sight and presence of each other, do he, which consists of _____ pages, including the page(s) which contain the witness signatures, was signed in our sight and presence by _____________________________ (the "Testator"), who declared this iesses should not receive assets under this Will.) We, the undersigned, hereby certify and declare under penalty of perjury under the laws of the State of ____________________ that the above instrument___________________ Name: _________________________________________ (Notice to Witnesses: Three (3) adults must sign as witnesses. Each witness must read the following clause before signing. The witn am of legal age and sound mind, that I make this under no constraint or undue influence and ask the Witnesses named below to witness my signature. Testator's Signature: ____________________________ WITNESS WHEREOF, I have signed my name below to this Will, this _____ day of ____________________, ______. at ____________________ (city), that I declare this to be my Last Will and Testament, that Ivision of this Will is declared invalid, illegal or unenforceable, any invalidity, illegality or unenforceability should affect only that provision and all other provision should remain effective. INry gift together with the income therefrom shall remain the separate property of a beneficiary hereunder, free from all matrimonial rights or controls by his or her spouse. 6. Severability. If any pro be assigned or anticipated, or fall into any community of property, partnership or other form of sharing or division of property which may exist between any beneficiary and his or her spouse, and evecomprising the respective shares shall be determined by such beneficiaries if they can agree, and if not, by my Executor. 5. Matrimonial Rights. No gift, or the income therefrom, under this Will shallconstitute fraudulent conduct or bad faith. 4. Beneficiary Disputes. If any bequest requires that the bequest be distributed between or among two or more beneficiaries, the specific items of property tural person from any and all claims or expenses in connection with or arising out of that fiduciary's good faith actions or non-actions as the fiduciary, except for such actions or non-actions which Fiduciary. No fiduciary who is a natural person shall, in the absence of fraudulent conduct or bad faith, be liable individually to any beneficiary of my estate, and my estate shall indemnify such nathe beneficiary is living on the thirtieth day after the date of my death. Initials: __________ Testator __________ Witness __________ Witness __________ Witness Page 5 of ______ 3. Liability ofnting such adoption. 2. Thirty Day Survival Requirement. For the purposes of determining the appropriate distributions under this Will, Each beneficiary shall be deemed not to have survived me unless ild" and "descendant" shall include an adopted person and such adopted person's descendants, if, but only if, the adopted person is not more than twelve years of age on the date of the court order gra to include all genders, and the use of the singular the plural, and vice versa. and any pronouns shall be taken to refer to the person or persons intended regardless of gender or number The terms "chhis Will are inserted for reference purposes only and are not to be considered as forming a part of this Will in interpreting its provisions. Throughout this Will the use of any gender shall be deemedI MISCELLANEOUS PROVISIONS The provisions in this Will for the distribution of my estate shall be supplemented by the following: 1. Paragraph Titles and Gender. The titles given to the paragraphs of tiscretion shall be binding upon all of the beneficiaries and shall not be subject to any question or review, by any person, official, authority, court or tribunal whatsoever or whomsoever. ARTICLE VIonsidered as being other than an impartial exercise of their duties hereunder or as not being maintenance of an even-hand among the beneficiaries and all such exercise of their powers, authority and d or otherwise, of the beneficiaries, whether or not such exercise may have the effect of conferring an advantage on any one or more of the beneficiaries or would otherwise, but for the foregoing, be centatives by reason of the exercise of such discretion. The Executor shall exercise the powers, authority and discretion granted herein in what Executor deems to be the best interest, whether monetaryd other professional fees. The Executor shall be fully protected in exercising any discretion granted to them in my Will and shall not be liable to the beneficiaries or their heirs or personal represor deem same advisable. 11. Pay all necessary and reasonable expenses and costs incurred in connection with administering my estate, including but not limited to attorney, accountant, agent, broker anstate may have against others for such consideration or no consideration and upon such terms and conditions as the Executor may deem advisable and to refer to arbitration all such claims if the Execute or continue any partnership or business in which I may have an interest at the time of my death. 10. Compromise, settle, waive or pay any claim or claims at any time owing by my estate or which my ecise of discretion, entered into by the Executor in good faith. Initials: __________ Testator __________ Witness __________ Witness __________ Witness Page 4 of ______ 9. Windup, dissolve, settlperson, whether beneficiary or otherwise, by reason of any loss, claim, tax or other cost experienced by any such person or by my estate resulting from any election, determination, designation or exerdy of any other country, state or territory, and such exercise of discretion by the Executor shall be conclusive and binding upon all the beneficiaries hereof. The Executor shall not be liable to any permitted by any statute or regulation enacted by the federal government of the United States of America, by the legislature or government of any state, or by any other legislative or governmental bor responsible for any injury to, consumption of or loss of any such property so used. 8. Make or refrain from making, in Executor's absolute discretion, any elections, determinations, and designationste to use any tangible personal property or real property, without paying any rent, without giving any bond or security and without liability for any loss or damage. The Executor shall not be liable oionary or future interest shall be sold prior to falling into possession and no such interest not actually producing income shall be treated as producing income. 7. Permit any beneficiaries of my esta Executor's absolute discretion without responsibility for loss to the intent that investments or assets so retained shall be deemed to be authorized investments for all purposes of my Will. No revers market value and cause any share to be composed of money, property or undivided fractional share in property. 6. Retain any of my investments or assets in the form existing at the date of my death atny part or parts thereof for such length of time as they may think best. Make any division or distribution of my residuary estate in money or in other property or partly in both upon the basis of fairn such manner and upon such terms, and either for cash or credit or for part cash and part credit as they may in their absolute discretion decide upon, or to postpone such conversion of my estate or ahe Executor may be beneficially interested in the property or any part thereof so valued. 5. Sell, call in and convert into money any part of my estate not consisting of money at such time or times, itting aside or payment and the decision of the Executor shall be final and binding upon all persons concerned, notwithstanding any fluctuation in market value and notwithstanding that one or more of tg aside or payment, and I expressly will and declare that the Executor shall in their absolute discretion fix the value of my estate or any part thereof for the purpose of making any such division, seof my real or personal estate or set aside or pay any share or interest therein either wholly or in part in the assets forming my estate at the time of my death or at the time of such division, settiny on any such real estate upon the security of any mortgage or mortgages and to pay off any mortgage or mortgages which may be in existence at any time forming part of my estate. 4. Make any division manage any such property. The Executor shall also have the right to renew and keep renewed any mortgage or mortgages upon any real estate forming part of my estate or any part thereof, to borrow moneitness __________ Witness __________ Witness Page 3 of ______ 3. To accept surrenders of leases and tenancies, to expend money in repairs, alterations, rebuilding and improvements and generally toreof, including the cost of keeping such property in adequate condition and repair, in the manner and to the extent that the Executor shall deem advisable. Initials: __________ Testator __________ W2. Take charge of any real property as part of the probate administration of my estate for such period as the Executor shall determine; collect any income therefrom; and pay the taxes and expenses theeds, mortgages, leases or other instruments and documents as may be necessary to effect such a sale, mortgage, lease or other disposition. The power of sale herein is discretionary and not mandatory. ch prices, and upon such terms, credits and conditions as may be deemed advisable, without order of court and without notice to anyone. I also give to the Executor power to execute and deliver such de options, partition, exchange, mortgage, or otherwise encumber or dispose of all or part of any real or personal property that may be included in my estate in such manner and for such purposes, for sur and in addition to other powers and authority granted by law or necessary or appropriate for proper administration of my estate, the Executor shall have the right and power to: 1. Lease, sell, grant intervention by the probate court. No bond, security or surety shall be required of any Executor serving hereunder. ARTICLE VI POWERS OF EXECUTOR In addition to the existing authority of the Executocation, order or direction of the court having jurisdiction over my estate, using "informal", "unsupervised", or "independent" probate or equivalent legislation designed to operate without unnecessaryay be acting as such from time to time whether original or substituted and whether one or more. To the extent permitted by law, the Executor shall have the right to administer my estate without adjudid of the first aforementioned Executor. References to "Executor" in this my Will shall include each Executor, Executrix, and Personal Representatives of my Will, my estate or any portion thereof who mentity cannot, does not or is unable to serve or continue to serve as Executor for any reason, I appoint ___________________________________, , to be the Executor of this my Will in the place and steaution shall be a sufficient discharge to the Executor. ARTICLE V NOMINATION OF EXECUTOR I appoint ___________________________________, ("Executor") as the Executor of this my Will. If such person or s __________ Witness __________ Witness Page 2 of ______ the time of the distribution or to any other person the Executor may consider to be a proper recipient thereof. Receipt of any such distribto the beneficiary or to a parent, guardian, conservator, committee of such person, trustee of such person, person with whom the beneficiary resides at Initials: __________ Testator __________ Witnesntitled to any share in my estate before attaining the age of majority or while under any other disability, I authorize the Executor to nevertheless make any distribution for any such person directly as if I had died intestate at the time fixed for distribution under this provision. Except as may be specifically otherwise provided herein or directed otherwise by law, if any person should become eurvive me, my residuary estate shall be distributed to my heirs-at-law, their identities and respective shares to be determined under the laws of the State of ________________________, then in effect,___________ ____________________________________________________________________________ ____________________________________________________________________________ If any such beneficiary does not s shares per stirpes. If none of the named child(ren) or their descendants, survive me, I direct that my residuary estate be distributed in equal shares per stirpes to: ________________________________ributed, bequeathed and given to my child(ren) _____________________________________________________________________ (name(s)). If more than one child is named, then the distribution shall be in equalmore than one child is named, then the distribution shall be in equal shares per stirpes. Residuary Estate I direct that my residuary estate, including any real property and personal property, be distbuted with my residuary estate. Primary Residence All my interest in my primary residence or homestead, if any, shall be distributed to my child(ren) ___________________________________ (name(s)). If th my residuary estate. _____________________________________________ shall be distributed to ___________________________________. If this beneficiary does not survive me, this bequest shall be distrisiduary estate. _____________________________________________ shall be distributed to ___________________________________. If this beneficiary does not survive me, this bequest shall be distributed wiestate. _____________________________________________ shall be distributed to ___________________________________. If this beneficiary does not survive me, this bequest shall be distributed with my reree upon or after my death pursuant to any agreement with respect to such property. ARTICLE IV DISPOSITION OF PROPERTY Specific Bequests I direct that the following specific bequests be made from my _ This direction shall not extend to or include any such taxes that may be payable by a purchaser or transferee in connection with any property transferred to or acquired by such purchaser or transfeThe Executor shall not seek reimbursement from any beneficiary for the payment of the taxes. Initials: __________ Testator __________ Witness __________ Witness __________ Witness Page 1 of _____t or benefit given or conferred by me either during my lifetime or by survivorship. The payment of the taxes shall be made regardless of whether the taxes are owed by my estate or by any beneficiary. the taxes shall be made regardless of whether the taxes are owed on property passing under this Will or any codicil hereto, outside of this Will, in connection with any insurance on my life or any gifidue of my estate. The Executor shall create, out of the residue, a separate fund for the purpose of paying any inheritance taxes in the amount necessary to pay said inheritance taxes. The payment of f and charged to the capital of my general estate. All taxes (including income taxes and inheritance taxes) and any interest and penalties thereon owed because of my death shall be paid out of the res statute or rule of court and without order of any court. ARTICLE III PAYMENT OF DEBTS AND EXPENSES I direct that my just debts, testamentary expenses and expenses of last illness be first paid out oion or burial and interment, including the disposition of the ashes or the acquisition of any burial site and the erection and engraving of monuments and markers, regardless of any limitation fixed by_______________________________ Born on _________________ ARTICLE II FUNERAL & BURIAL EXPENSES I authorize the Executor of my Will to pay such sums as the Executor deems proper for my funeral, crematd. I have the following adult child(ren): Name: _______________________________________ Born on _________________ Name: _______________________________________ Born on _________________ Name: _______________________________ (state), revoke my former Wills and Codicils and publish and declare this to be my Last Will and Testament. ARTICLE I MARRIAGE & CHILDREN I am single. I have never been marrie of this document should be discussed with a tax professional. Last Will And Testament Of ______________________ I, _____________________________________ (name), of _______________________ (county), n attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising outa substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting aeferred to as the "Marital Deduction". If the recipient spouse is not a U.S. citizen, the deduction is limited (it was $100,000 in 2006). This information and these forms are not intended and are not erty you are holding in trust; any joint property you own In addition, each individual may leave an unlimited amount to his or her spouse upon death without any federal estate tax liability. This is r, art, and other personal effects); [] partnership (business) interests; [] individual retirement accounts and qualified employee benefit plans; [] the face value of any life insurance policy; [] propf all of the assets in your estate. Assets may include the following: [] real estate; [] stocks and bonds; [] bank accounts; [] tangible personal property (household furnishings and furniture, jewelryvel, Information about Wills ­ Page 2 you really shouldn't use this will and should consult with tax professionals and an attorney. Before using this Will, it may be helpful to determine the value ofederal estate tax. As your estate approaches $2,000,000 in value and exceeds that amount, the greater your need for professional estate tax planning advice. If your assets come near the $2,000,000 leal's estate. For a person dying from 2006 to 2008, that credit is $2,000,000. The credit is available to each individual and his or her spouse. Estates totaling $2,000,000 or more could be subject to should have an understanding of tax laws. Federal tax law provides that upon the death of an individual, there is a credit against the estate tax otherwise due on a portion of the value of an individuny life situation where this Will is to be used as the principal estate planning document. If you have a large estate, you may need more complicated planning to reduce or limit death taxes. Testators or to require the witnesses to testify. New Hampshire permits self proving, but requires the affidavit to be in a specific format similar to the one included in our wills. The Will is for anyone in aoven" in court, like any other will. In Ohio, Maryland, California and the District of Columbia, the courts have some latitude to accept a will as self proved, to require an affidavit of the witnesseswill be of no use in those states. However, including the affidavit in those states will not invalidate the Will (since it is a separate document from the Will). In those states it will have to be "pre influence, lack of testamentary capacity, or prior revocation. A few states like Louisiana, Maryland, Ohio and Vermont (as of 2003) do not have statutes permitting self proving wills. The affidavit were followed. The Affidavit can also be useful if witnesses are not available when they are needed.. However, even with the Affidavit, the Will may still be subject to contest on such grounds as undueach saw the Testator sign the will and that the formalities for signing a Will were followed. The Affidavit may eliminate the need to have witnesses testify, that the formalities in signing the Will death of the Testator. Before the adoption of more modern laws, all wills were proved by having one or more of the witnesses come into court and testify under oath, or through sworn affidavits, that required formalities were observed when the Will was signed. The Affidavit does not affect the validity or legality of the Will. However, it can speed up the admission of the Will to probate after theand will not be governed by this Will. The Will has an enclosed self-proving affidavit, which contains the Testator's acknowledgment and the affidavit of the witnesses, made before a Notary, that all ld jointly with rights of survivorship, assets with beneficiary designations (such as life insurance or employee benefit plans), and assets held in trust generally will not be required to be probated ) as specified by the Testator. This Will does not avoid probate for the Testator's estate. It merely directs how the assets which are individually owned by the Testator will be distributed. Assets hend use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information about Wills This Will distributes the assets of the person making the Will (the "Testator"cal attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase aate to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a lolity for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from sted by a lawyer in their new state to make sure it meets local requirements. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitabict estate planning can vary over time and from place to place. All wills should be reviewed by a lawyer before they are signed. If the Testator moves to another state, the current will should be checke Will calls for distribution in percentages, make sure that the total of all of the beneficiaries' percentage's equal 100%. Check the totals before signing the Will. State and federal laws which affeother spouse dies. The Will may be invalid if a spouse receives nothing or only a small portion of the estate. Consult an attorney if you wish to disinherit a spouse or any children. If any part of th the Testator's marital status changes, if the Testator has a child or if a named beneficiary or one of the Executors dies. Most state laws guarantee a minimum share of an estate to a spouse when the usually disregarded. If changes are desired, the original and all copies should be destroyed and an entirely new Will should be written and signed. New wills are commonly necessary when, for example,his Will should be discussed with a competent tax advisor. If it becomes necessary to change the Will, do not modify it by adding, deleting, or changing words on the face of the Will. Such changes are & Instructions ­ Page 4 This Will is not designed to reduce taxes. Estate taxes, if any, are based on the size of the total taxable estate and other matters. The tax results of the choices made in t in trust. In addition, the distribution of retirement plan benefits, life insurance proceeds and survivor benefits arising in other contracts and plans are not normally governed by a will. Checklistwould automatically pass to another person by operation of law or by any contract. For example, the Will does not dispose of property held in joint tenancy with rights of survivorship or property held by the Testator and may also (if Testator so wishes) be provided to the person named as Executor / Personal Representative. This Will does not dispose of property that, on the death of the Testator, l "copy" of a will should be prepared. While photocopies may be used for reference purposes, only the original can be admitted to probate. Copies are rarely accepted. A copy of the Will should be keptoriginal of the Will should be kept in a secure location such as a safe deposit box at a bank or lawyer's office. Unlike other legal instruments where multiple originals are prepared, only one originanies) before naming them as a Personal Representative, to make sure that they are willing and can serve. If you select a bank or trust company, be sure to check into their fees for such services. The ortant to pick a person (or bank or trust company) that can be trusted to handle financial matters and to deal appropriately with family members. It is best to talk to people (and banks or trust compa (excluding i.e. not counting the self-proving affidavit) should be entered by hand in the bottom right of each page. The Personal Representative / Executor, should be picked carefully. It is very impe a Notary or other person authorized to take acknowledgments and administer oaths. The affidavit states that all required formalities were observed when the Will was signed. The total number of pagesself-proving affidavit (called "Proof of Will" in some states) and attach it to the end of the Will. The Affidavit contains the Testator's acknowledgment and the affidavit of the witnesses, made beford by the Witnesses. The page with the self-proving affidavit, if included, should not be counted because the affidavit is not a part of the Will itself. The Testator and the witnesses should sign the ty of the Will at a later date (i.e. if this Will revokes an earlier Will). The total number of pages in the Will, including the page(s) on which the witness signature lines appear, should be indicateis signing the Will freely and willingly. Wherever requested, the date should be filled in (preferably by hand), with the date of the actual signing. This step could be crucial to determine the validill. All witnesses must sign their names in the presence of the Testator and each other and of the notary public. The witnesses must be satisfied that the Testator is an adult of sound mind and he/she t is a good idea for the Testator to initial the bottom of each page of the Will. This can prevent subsequent substitution of pages. The witnesses should also initial the bottom of each page of the Wi: "The document Checklist & Instructions ­ Page 3 I am about to sign is my Last Will and Testament. I am signing it freely and voluntarily," or similar words. Although not required in most states, iment that is about to be signed, is intended to be the Testator's Last Will and Testament. However, the witnesses don't need to read or know the contents of the Will. For example, the Testator can sayl witnesses and the notary should watch the Testator sign the Will. The notary public is needed for the self proved affidavit. Before signing the Will, the Testator should orally declare that the docualid for any reason or if one of the witnesses can't be located. The witnesses should not be beneficiaries under the Will. For example children, spouses, heirs or executors should not be witnesses. Als and a notary public. Important Note: Vermont requires three witnesses. The signature of a third witness can provide additional protection if the signature of one of the witnesses is deemed to be invto a share of the estate. Although most states only require two witnesses, the Will should be signed by the Testator in the presence of three (3) qualified, competent, disinterested and adult witnesseing of "sound mind" usually means that the Testator knows that he/she is signing a Will, is familiar with the property and the value thereof and knows about relatives and others who might be entitled or to require the witnesses to testify. The Testator (i.e. the person who is writing the Will) must be of "sound mind" when signing the Will and must be of legal age (i.e. eighteen in most states). Beven" in court, like any other Will. In Ohio, Maryland, California and the District of Columbia, the courts have some latitude to accept a will as self proved, to require an affidavit of the witnesses need to be completed. However, signing and including the affidavit in those states will not invalidate the Will (since it is a separate document from the Will). In those states it will have to be "pront Note: A few states like Louisiana, Maryland, Ohio and Vermont (as of 2003).do not have specific statutes permitting self proving wills. The affidavit will be of no use in those states and does not states that all required formalities were observed when the Will was signed. The Affidavit needs to be completed and signed, by the Testator, all Witnesses and a Notary in front of each other. Importaesses must provide and fill out: [] name of state; [] number of pages; [] name of testator; []witness signatures and info Affidavit: The enclosed Affidavit (although technically not part of the Will) y, and making distributions to the beneficiaries Article VII: Contains miscellaneous provisions Signature Block: Testator needs to fill out: [] day month year city; []Signature; []name Witnesses: Witnmust provide and fill out [] the name of executor; [] name of alternate executor. Article VI: Powers of Executor empowers the representative to deal with matters like taxes, taking care of the propertadministration expenses and taxes out of the testator's estate. After paying debts and expenses, the Personal Representative will pay whatever is left to the beneficiaries named in the will. Testator the responsibility (after the testator's death) of managing the testator's property. The Personal Representative is also responsible for paying outstanding debts, Checklist & Instructions ­ Page 2 rsonal Representative (i.e. Executor) and alternate; It allows the Testator to name an Executor to administer the estate, and an alternate in case the first choice cannot serve. The Executor will havernate" beneficiaries to whom the residuary estate will be given if child(ren) predecease Testator. [] state under whose laws the will is made Article V: Deals with the appointment of the Testator's Pee provided, but you can add as many as you need). []name of child(ren) to whom the primary residence (if any) is given; []name of child(ren) to whom the residuary estate will be given; []name of "alted the residuary estate to the child(ren). Testator must provide and fill out: [] description of property (or dollar amount); [] name(s) of person/entity property is given to (three blank paragraphs ars of specific property, primary residence and residuary property.. Allows Testator to give specific dollar amounts or other property to specific persons or charities and gives any primary residence anhildren. You can add or remove spaces for names as necessary. Article II: Authorizes payment of funeral and Burial expenses. Article III: Authorizes payments of debts and expenses. Article IV: Disposeounty and []state Article I: Gives the name(s) of the child(ren). Testator must provide and fill out [] name(s) of child(ren) and date of birth for each child. Three spaces are provided for names of c Title: Enter name of Testator in blank space under title "Last Will and Testament of". Introduction: Contains preliminary information about the will. Testator must provide and fill out: [] name, [] cdivided into various sections. The content of each section is explained below. Some sections require information to be entered in the space provided. The enclosed Affidavit also needs to be completed. the assets of the Testator (i.e. person making the will) to the child(ren) and to specific beneficiaries named in the Will. This Will is suitable for estates worth less than $2,000,000. This Will is ill ­ Single Person with Adult Children and selfproved affidavit. This Will is for a Single Person with Adult Children, who has never been married, and includes a self-proved affidavit. It distributesChecklist and Instructions Will ­ Single Person with Adult Children This package contains (1) Checklist and Instruction for Will ­ Single Person with Adult Children; (2) Information about Wills; (3) W ConnecticutConnecticut Commissioner of the Superior Court Notary Public My commission expires: _____________________________ (Print or type name of all persons signing under all signatures). -3- _____ _________________________________ (Witness Signature) _________________________________ (Witness Signature) Subscribed and sworn to before me this _____________ day of ______________ 20______ mind, able to understand the nature and consequences of said document, and under no improper influence, and we make this affidavit at the author's request this _____________ day of ______________ 20_thor's presence, at the author's request, and in the presence of each other; that at the time of the execution of said document the author appeared to us to be eighteen years of age or older, of sound the author subscribed, published and declared the same to be the author's instructions, appointments and designation in our presence; that we thereafter subscribed the document as witnesses in the auuctions, the appointments of a health care agent and an attorney- in-fact, the designation of a conservator for future incapacity and a document of anatomical gift by the author of this document; that________________ STATE OF CONNECTICUT ) ) COUNTY OF _______________________ ) ss .... We, the subscribing witnesses, being duly sworn, say that we witnessed the execution of these health care instr_____ Address: ______________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________nt in the author's presence and at the author's request and in the presence of each other. _____________________________________________ (Witness Signature) Print Name: ______________________________ able to understand the nature and consequences of health care decisions at the time the document was signed. The author appeared to be under no improper influence. We have -2- subscribed this docume_________ This document was signed in our presence, by _______________________________________ (Name), the author of this document, who appeared to be eighteen years of age or older, of sound mind and document may rely upon it unless such party has received actual notice of my revocation of it. ______________________________________________ (Signature) (Date) ___________________________________________________________________ These requests, appointments, and designations are made after careful reflection, while I am of sound mind. Any party receiving a duly executed copy or facsimile of thisa) of section 19a-279f of the general statutes ______ (2) .... these limited purposes ________________________________ _______________________________________________________ _______________________________________________________________________________ _______________________________________________________ to be donated for: (check one) ______ (1) .... any of the purposes stated in subsection (tomical gift, if medically acceptable, to take effect upon my death. I give: (check one) ______ (1) any needed organs or parts ______ (2) only the following organs or parts _________________________ _g or unable to serve as my conservator, I designate ____________________________________________________________ No bond shall be required of either of them in any jurisdiction. I hereby make this ana need to be appointed, I designate ____________________________________________________________ be appointed my conservator. If ____________________________________________________________ is unwillin, I appoint ____________________________________________________________ to be my alternative health care agent and my attorney- in-fact for health care decisions. If a conservator of my person shouldmaintaining physical comfort. If ____________________________________________________________is unwilling or unable to serve as my health care agent and my attorney- in- fact for health care decisionsnt as long as such action is consistent with my wishes concerning the withholding or removal of life support systems; and -1- (4) Consent to any medical treatment designed solely for the purpose of g the withholding or removal of life support systems; (2) Take whatever actions are necessary to ensure that any wishes are given effect; (3) Consent, refuse or withdraw consent to any medical treatmeo reach and communicate an informed decision regarding treatment, my health care agent and attorney- in- fact for health care decisions is authorized to: (1) Convey to my physician my wishes concerninnd my attorney- in- fact for health care decisions. If my attending physician determines that I am unable to understand and appreciate the nature and consequences of health care decisions and unable t I do not intend any direct taking of my life, but only that my dying not be unreasonably prolonged. I appoint ____________________________________________________________ to be my health care agent ae not limited to: Artificial respiration, cardiopulmonary resuscitation and artificial means of providing nutrition and hydration. I do want sufficient pain medication to maintain my physical comfort.s an irreversible condition in which I am at no time aware of myself or the environment and show no behavioral response to the environment. The life support systems which I do not want include, but ar, will, in the opinion of my attending physician, result in death within a relatively short time. By permanently unconscious I mean that I am in a permanent coma or persistent vegetative state which ie and not be kept alive through life support systems. By terminal condition, I mean that I have an incurable or irreversible medical condition which, without the administration of life support systems_________________________________________________, the author of this document, request that, if my condition is deemed terminal or if I am determined to be permanently unconscious, I be allowed to diician, you may rely on any decision made by my health care agent, attorney- in- fact for health care decisions or conservator of my person, if I am unable to make a decision for myself. I, ___________ntment of my health care agent and my attorney- in- fact for health care decisions, the designation of my conservator of the person for future incapacity and my document of anatomical gift. As my phys OF ANATOMICAL GIFT To any physician who is treating me: These are my health care instructions including those concerning the withholding or withdrawal of life support systems, together with the appoiCTIONS. MY APPOINTMENT OF A HEALTH CARE AGENT, MY APPOINTMENT OF AN ATTORNEY-IN-FACT FOR HEALTH CARE DECISIONS, THE DESIGNATION OF MY CONSERVATOR OF THE PERSON FOR MY FUTURE INCAPACITY AND MY DOCUMENTprofessional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -2- Power of Attorney for Health Care THESE ARE MY HEALTH CARE INSTRUticular situation. You should also consult an attorney whenever a document is negotia ted with another party. Any possible tax consequences arising out of this document should be discussed with a tax be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your paro their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should onlyfollowing form: (Form included below) [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as tconservator of the person for future incapacity and a document of anatomical gift. Any such document shall be signed and dated by the maker with at least two witnesses and may be in the substantially r older may execute a document which contains health care instructions, the appointment of a health care agent, the appointment of an attorney-in- fact for health care decisions, the designation of a ns, appointment of health care agent, attorney-in-fact for health care decisions, designation of conservator of the person for future incapacity and anatomical gift. Any person eighteen years of age on" means the physician selected by, or assigned to, the patient and who has primary responsibility for the treatment and care of the patient. Sec. 19a-575a. Form of document re health care instructiotient; (B) an adult son or daughter of the patient; (C) either parent of the patient; (D) an adult brother or sister of the patient; and (E) a grandparent of the patient; -1- (9) "Attending physiciacare, including the withholding or withdrawal of life support systems; (8) "Next of kin" means any member of the following classes of persons, in the order of priority listed: (A) The spouse of the paicate an informed decision regarding the treatment; (7) "Living will" means a written statement in compliance with section 19a-575a containing a declarant's wishes concerning any aspect of his health Incapacitated" means being unable to understand and appreciate the nature and consequences of health care decisions, including the benefits and disadvantages of such treatment, and to reach and commune environment; (5) "Health care agent" means an adult person to whom authority to convey health care decisions is delegated in a written document by another adult person, known as the principal; (6) "udes permanent coma and persistent vegetative state and means an irreversible condition in which the individual is at no time aware of himself or the environment and shows no behavioral response to thcondition which, without the administration of a life support system, will result in death within a relatively short time, in the opinion of the attending physician; (4) "Permanently unconscious" incltreatment including surgery, treatment, medication and the utilization of artificial technology to sustain life; (3) "Terminal condition" means the final stage of an incurable or irreversible medical , but are not limited to, mechanical or electronic devices including artificial means of providing nutrition or hydration; (2) "Beneficial medical treatment" includes the use of medically appropriate hen applied to an individual, would serve only to postpone the moment of death or maintain the individual in a state of permanent unconsciousness. In these circumstances, such procedures shall includeonnecticut Statutes. Sec. 19a-570. Definitions. For purposes of this section and sections 19a-571 to 19a-580c, inclusive: (1) "Life support system" means any medical procedure or intervention which, wlth Care Directive Form. This Connecticut Advance Health Care Directive is based Chapter 368 Section 19a-570 et. Seq. of the Connecticut Statutes. The following are useful excerpts from the relevant CInformation and Instructions Connecticut Advance Health Care Directive This package contains (1) Information and Instructions for Connecticut Advance Health Care Directive; (2) Connecticut Advance Hea ConnecticutConnecticut for the purposes therein contained. In witness whereof I hereunto set my hand. _____________________________ Notary Public My commission expires:______________________ Quitclaim Deed - 2 nally appeared ______________________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that he/she executed the same __________________________ State of Connecticut County of ______________ } ss. On this the _____________ day of _____________, 20__, before me, _____________________, the undersigned officer, personce: _____________________________________ (Witness Signature) Print Name: ___________________________ Signed in my presence: _____________________________________ (Witness Signature) Print Name: _tclaim Deed on __________________, 20 __. ____________________________________________ ____________________________________________ Type or Print Name of Grantor Quitclaim Deed - 1 Signed in my presessigns shall have claim or demand any right or title to the property described above, or any of the buildings, appurtenances and improvements thereon. IN WITNESS WHEREOF, Grantor has executed this Quior's right, title and interest in and to the above described property unto Grantee, Grantee's heirs, successors and/or assigns forever; so that neither Grantor nor Grantor's heirs, successors and/or acribed as follows: [Insert legal description] SUBJECT TO all, if any, valid easements, rights of way, covenants, conditions, reservations and restrictions of record. TO HAVE AND TO HOLD all of Grant parcel of land, with all the buildings, appurtenances and improvements thereon, if any, in the City of __________________________, County of ________________________________, State of Connecticut dessideration, the receipt and sufficiency of which is hereby acknowledged, Grantor hereby REMISES, RELEASES, AND FOREVER QUITCLAIMS to Grantee, all right, title, interest and claim to the plot, piece orantee") whose address is _____________________________________________________. FOR A VALUABLE CONSIDERATION, in the amount of _______________________ DOLLARS ($______) and other good and valuable conn ___________________, 20_____, between ____________________________ ("Grantor") whose address is _________________ __________________________________________ and ________________________________ ("Gr please return this deed and tax statements to: Escrow No.: For recorder's use only Title Order No.: QUITCLAIM DEED KNOW ALL MEN BY THESE PRESENTS THAT: THIS QUITCLAIM DEED, made and entered into otiating any document with another party. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Recording requested by: and when recorded,are not a substitute for legal advice. These forms should only be a starting point for you and should not be used without consulting with an attorney first. An Attorney should be consulted before negoce. [_] Depending on the type of document, additional requirements may apply. Nonconforming documents may be returned unrecorded or may be charged additional fees [_] These forms are not intended and d. Verify that the legal description is correct. [_] A Quitclaim Deed may require other documents to be filed with it. Please check your local requirements with your local Recorder's (or similar) offiffective against third parties. Although witnesses are not required in all states, it is generally a good idea to use them. [_] Documents referencing land should include a legal description of the lan the Quitclaim Deed before a Notary and two witnesses. Among other things, Notarization will allow the Quitclaim Deed to be recorded as a public record. Without filing, the Quitclaim Deed may not be eInstructions & Checklist for Quitclaim Deed Connecticut (Individual) [_] This package contains (1) Instructions and Checklist for Quitclaim Deed (2) Quitclaim Deed [_] The Grantor should date and sign ConnecticutConnecticut _____________ Name of Survivor: _______________________________ Address: ____________________________________________ City: _______________________________________________ State: __________________________________urposes (strike any of the following you do not want): (1) Transplant (2) Therapy (3) Research (4) Education Date: __________________ Signature of Survivor: __________________________________ Printed_______________ ________________________________________________________________________ ________________________________________________________________________ III. The gift is for the following pthe applicable box): Give any needed organs, tissues, or parts, OR Give the following organs, tissues, or parts only: _______________________ _________________________________________________________ity and state). I. I survive the decedent as (mark the appropriate box): spouse; adult son or daughter; parent; adult brother or sister; grandparent; or guardian of the decedent. II. I hereby (mark this anatomical gift from the body of __________________________________(name of decedent) who died on _____________, 20___ at_______________________________ in ____________________________________ (corney should be consulted for all serious legal matters. Anatomical Gift by Next of Kin or Guardian of the Person Pursuant to the Uniform Anatomical Gift Act and the law of this state, I hereby make rruption) however caused and on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any way out of the use of these materials. An att direct, indirect, incidental, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loss of use, data, or profits; or business inteals are used at your own risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers of the forms, be responsible or liable for anym. These materials are provided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the materials for your particular needs. The materieated by use of these materials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers and Terms of Use" found at findlegalforms.con for the removal of a part from the body of the decedent, the physician, surgeon, technician, or enucleator removing the part knows of the revocation. Disclaimer No Attorney-Client relationship is cr a member of the person's class or a prior class. An anatomical gift by a person authorized under subdivision may be revoked by any member of the same or a prior class if, before procedures have beguoposing to make an anatomical gift knows of a refusal or contrary indications by the decedent. (3) The person proposing to make an anatomical gift knows of an objection to making an anatomical gift byAn anatomical gift may not be made by a person listed above if any of the following occur: (1) A person in a prior class is available at the time of death to make an anatomical gift. (2) The person pre decedent; (3) either parent of the decedent; (4) an adult brother or sister of the decedent; (5) a grandparent of the decedent; and (6) a guardian of the person of the decedent at the time of death ker for an authorized purpose, unless the decedent, at the time of death, has made an unrevoked refusal to make that anatomical gift: (1) the spouse of the decedent; (2) an adult son or daughter of th Gift Form An anatomical gift may be made any member of the following classes of persons, in the order of priority listed, may make an anatomical gift of all or part of the decedent's body or a pacemas made on behalf of the decedent by the next of kin or guardian. Included in this kit are the following: General Instructions for preparing your Anatomical Gift (by next of kin or guardian) Anatomicalt. As the next of kin or guardian, you can prepare and execute an Anatomical Gift on behalf of the decedent. This kit is designed to fulfill the obligations of the Uniform Anatomical Gift Act for giftFindLegalForms.com Information Donation Pursuant to the Uniform Anatomical Gift Act (by Next of Kin or Guardian) A loved one has died and you believe that he/she would desire to make an Anatomical Gif Connecticut