CLOSING STATEMENT G.L. c. 190B, § 3-1003 Estate of: First Name Middle Name Docket No. Commonwealth of Massachusetts The Trial Court Probate and Family Court Division Last Name Date of Death: I, First Name M.I. Last Name Personal Representative(s) (hereafter "Personal Representative") of the above-referenced estate, duly appointed on hereby states the following in support of the closure of administration of this (date) estate pursuant to G.L. c. 190B, § 3-1003: 1. The creditor claim period for this estate has expired. 2. The undersigned or a prior Personal Representative has fully administered the above-referenced estate by making payment, settlement, or other disposition of all lawful claims, debts, expenses of administration, federal and state estate taxes, inheritance taxes, other death taxes, and income taxes, except as explained as follows: 3. The assets of the estate have been distributed to the persons entitled to receive such assets in the amount and manner to which they were entitled. 4. OR The following claims, if any, remain undischarged: No claims remain undischarged. The Personal Representative has distributed the estate subject to possible liability with the agreement of the distributees. OR The following detailed arrangements have been made to accommodate outstanding liabilities: 5. The undersigned has provided notice and a copy of this Closing Statement to distributees of the estate, creditors or other claimants of whom the Personal Representative is aware whose claims are neither paid nor barred and has furnished a full account in writing of the Personal Representative's administration to the distributees whose interests are affected thereby. 6. No Court order prohibits the closing of this estate and there is no pending formal proceeding which would otherwise stay the informal closing of this estate. Administration of this estate is not supervised. American LegalNet, Inc. www.FormsWorkFlow.com MPC 850 (3/19/12) STCL page 1 of 2 RETURN OF SERVICE I, specified below: To: at: (address) (name) , hereby certify that notice was given to each interested person as by first-class mail certified mail on: hand delivery (date) To: at: (address) by first-class mail certified mail on: hand delivery (date) To: at: (address) by first-class mail certified mail on: hand delivery (date) To: at: (address) by first-class mail certified mail on: hand delivery (date) The following interested persons have waived notice and the waivers are filed with this Notice or are in the possession of the Court: SIGNED UNDER THE PENALTIES OF PERJURY I certify under the penalties of perjury that the foregoing statements are true to the best of my knowledge and belief. Date: Signature of Petitioner Information on Attorney for Petitioner, if any Signature of Attorney (Print name) (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) Primary Phone #: B.B.O. # Email: This Statement is filed for the purpose of closing the above-referenced estate. If no proceedings involving the Personal Representative are pending in the Court one (1) year after the Closing Statement is filed, the Personal Representative's closing statement may not be challenged, except for fraud or manifest error. American LegalNet, Inc. www.FormsWorkFlow.com MPC 850 (3/19/12) STCL page 2 of 2