CGS § 45a-624c. Written statement that designation of standby guardian in full force and effect.

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

STATEMENT THAT DESIGNATION OF A STANDBY GUARDIANIS IN FULL FORCE AND EFFECT

| STATE OF | } | SS:

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| COUNTY OF

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.

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Witness |

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.... L.S.

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Witness |