Conn. Gen. Stat. § 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 GUARDIAN IS IN FULL FORCE AND EFFECT

STATE OF | } | SS:

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.

.... |

Witness |

.... | .... L.S.

Witness |