Commonwealth of Massachusetts The Trial Court Probate and Family Court Department Docket No: Plymouth Division Succeeding Executor/Executrix Name of Decedent Domicile at Death (city or town) (street and no.) Date of Death (county) (zip) Will allowed Name and address of executor/executrix appointed Name and address of Petitioner(s) The petitioner(s) hereby certif that a copy of this document, along with a copy of the decedent's death certificate has been sent by certified mail to the Division of Medical Assistance, P.O. Box 15205, Worcester, Massachusetts 01615-9906 Petitioner(s) represent(s) that said executor/executrix has -- died -- resigned -- become incapacited - without having fully executed said will and pray(s) that he/she/they or some other suitable person of (street and no.) (zip) (county) (city or town) by appointed succeeding executor/executrix of the will -- with -- without -- sureties on his/her/their bond and, certif under the penalties of perjury that the statements herein contained are true to the best of his/her/their knowledge and belief. Date Signature(s) The undersigned hereby assent to the foregoing petition. DECREE All persons interested having been notified in accordance with the law or having assented and no objections being made thereto, it is decreed that of in the County of be appointed succeeding executor/executrix of the will of said deceased, first giving bond, with sureties, for the due performance of said trust. Date JUSTICE OF THE PROBATE AND FAMILY COURT Updated: 3/12/07 pcpfc.com - c.f.g. American LegalNet, Inc. www.FormsWorkflow.com For Petitioner: Docket No. Tel. No. Succeeding Executor/Executrix B.B.O.# Filed , 20 , 20 Allowed Tel. No. Citation Issued Returnable For Respondent: , 20 , 20 Recorded Vol. Page B.B.O.# Publication in the Instructions Refer to Massachusetts General Laws Chapter 193, Section 9. pcpfc.com - c.f.g. American LegalNet, Inc. www.FormsWorkflow.com