The written statement referred to in § 45a-624 shall be in substantially the following form:

STATEMENT THAT DESIGNATION OF A STANDBY GUARDIAN
IS IN FULL FORCE AND EFFECT

STATE OF } SS:
COUNTY OF

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Terms Used In Connecticut General Statutes 45a-624c

  • Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.

I, …. of …., state under penalty of false statement:

THAT …., of …., as principal, did on …., 20.., appoint me as standby guardian dated …., 20.., to execute a statement that a specified contingency had occurred;

THAT specified contingency was: ….

THAT specified contingency has occurred.

IN WITNESS WHEREOF, I have hereunto set my hand and seal under penalty of false statement.

….

Witness

….

…. L.S.

Witness