Court/Division Docket Number Case Name Role * Land CourtApplication for appointment asCommissioner for partition of real estate, G. L. c. 241, 247 12 Name:(type or print) Firm Name: Address: (Street and Number) (City or Town) (State)(Zip Code) Tel. No. B.B.O. # E-Mail Address Fax. No. I certify that I was admitted to practice before the Supreme Judicial Court on , that I remain in good standing topractice before the courts of the Commonwealth of Massachusetts, that I have had no discipline imposed within the last ten years, and that I havenever been convicted of any felony.I further certify that I have at least ten years experience practicing in the real estate field, including at least three cases involving the partition ofreal estate - at least one of which has been completed, either through partition on the ground or a sale.*Three partition cases in which I have been involved are:* As commissioner, attorney for petitioner or respondent, or as a G. A. L.I have currently in effect professional liability insurance that would cover my activities as a partition commissioner with coverage of $100,000 or more. The insurance company which issued the policy is: (Name of Company) The policy number is: The liability limits of the policy are: Have you ever served as a partition commissioner in the Commonwealth? Y N If yes, how many times ?I REQUEST and I WILL accept appointments from (please list no more than two counties), and I will comply withthe time standards that apply and govern completion of my work, as ordered by the Court. 1. 2.I have attached to this Application a copy of my resume, which is current, accurate and complete.I certify under the penalties of perjury that all of the above information is true. Date: SignatureMail to: Land Court, Three Pemberton Square, Boston, MA 02108, ATTN: Chief Justice Gordon H. Piper(10-29-18) www.mass.gov/courts/landcourt For Land Court Use Only: Received Approved American LegalNet, Inc. www.FormsWorkFlow.com