STATE OF CONNECTICUT
RECORDED (CONFIDENTIAL VOLUME):
COURT OF PROBATE
Type or print in black
Rev. 10/99 Page 1 of 2
Note: This form may be used for all children having the SAME parentage. A separate form MUST be used for any child or
children who are NOT of the same parent named herein.
I, ____________________________________of __________________________________________
(Name of Principal)
___________________________________, State of Connecticut, being of sound mind and after careful
reflection, do make this declaration under and pursuant to the provisions of Connecticut General Statutes§45a-624b as amended.
I hereby designate and appoint presently residing at: ___________________________________________
(Name of Standby Guardian)
('I'own/City) (State) (Zip Code)
as Standby Guardian of the person(s) of my minor child or children hereinafter named:
This guardianship shall take effect upon the execution of a Statement by my Standby Guardian that at least one of the following
contingencies has occurred. (Check applicable boxes.)
My standby guardian has signed a statement attesting that I have become
mentally incapacitated to the extent that I am no longer able to adequately care for my minor child or children.
My standby guardian has
signed a statement attesting that I have become physically debilitated to the extent that I am no longer able to adequately care for my minor
child or children.
My death has occurred as evidenced by a copy of my death certificate in the possession of such guardian OR
All previous appointments made by me for this purpose, if any, are hereby revoked.
I certify that other parent of my child or of my children named above is:
____________________________________[check and complete applicable box below. Please note.]
(Name of other Parent)
who has endorsed hereon consent to such appointment(s) as required by law.
who died ____________________________________, a resident of ________________________ .
(Date of Death of Other parent)
(Town or City and State)
whose guardianship rights were removed on _____________________________________________ by the
(Date of Removal)
(Name and Address of Court Issuing Decree of Removal)
whose parental rights were terminated on _________________________________________by the
(Date of Termination
(Name and Address of Court Issuing Decree of Termination)
NOTE: If NONE of these conditions is applicable to the other parent, OR if the whereabouts of the other parent is unknown, this form
CANNOT be used to designate a standby guardian. Application should instead be made to the Probate Court for the District in which each
minor resides or alternative relief under C.G.S.~§45a-603 through 45a-622.
NOMINATION OF STANDBY GUARDIAN
CM-27 Rev. 10/99
on Page 2)