Sec. 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
COUNTY OF )
)
)SS:
      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
      (P.A. 94-207, S. 3; P.A. 99-84, S. 26.)
      History: P.A. 99-84 substituted "statement" for "affidavit" and added "under penalty of false statement" and deleted 
the attestation clause for Commissioners of the Superior Court and Notaries Public; (Revisor's note: In 2001 the references 
in this section to the date "19.." were changed editorially by the Revisors to "20.." to reflect the new millennium).