DEVISEES G. L. c. 190B, � 3-301 Original Form Estate of: First Name Middle Name Docket No. Commonwealth of Massachusetts The Trial Court Probate and Family Court Amended Form Division Last Name Date of Death: Form Use: This form must be used to identify a Decedent's devisees. Devisees are persons, entities, charitable organizations, or trusts designated in a will to receive the Decedent's personal or real property. In the case of a devise to an existing trust or trustee, or to a trustee or trust established by the will, the trust or trustee is the devisee and the beneficiaries are not devisees. For additional information, the Massachusetts Uniform Probate Code, G. L. c. 190B should be consulted. Instructions: Complete ALL applicable sections of this form. For step by step instructions on how to complete this form, click on the Instructions link above or see Instructions MPC 959. ALL PETITIONERS MUST COMPLETE LINE 1 AND LINE 2. 1. The Decedent left a will dated . The dates of all codicils are: . The will and any codicils are referred to as the will. 2. The following devisees named in the will to inherit personal or real property were living at the time of the Decedent's death. (Note: If the devisee is a trust, list the name of the trust and trustees. If any devisee is a charity, list the name of the charity and provide notice to the Massachusetts Attorney General. See G. L. c. 190B and Uniform Practice XXXIV). NAME OF DEVISEE ADDRESS (omit if since deceased) RELATIONSHIP TO DECEDENT A MINOR Yes Yes Yes 3. The following devisees named in the will to inherit personal or real property were not living at the time of the Decedent's death. NAME OF PREDECEASED DEVISEE DATE OF DEATH RELATIONSHIP TO DECEDENT 4. If the will names one or more persons to take in place of the pre-deceased devisee, or if the anti-lapse statute (G. L. c. 190B, � 2-603) applies, list the contingent devisee(s). Do not include residuary devisees named elsewhere. NAME OF CONTINGENT DEVISEE ADDRESS (omit if since deceased) RELATIONSHIP TO DECEDENT A MINOR Yes Yes American LegalNet, Inc. www.FormsWorkFlow.com MPC 163 (4/15/16) DEV page 1 of 2 ALL PETITIONERS MUST COMPLETE LINE 5 AND LINE 6, if applicable. 5. NONE of the devisees are under legal disability except for: REPRESENTED BY NAME OF DEVISEE LEGAL DISABILITY * (Guardian ad litem required unless waived. See Instructions) NAME/ADDRESS OF REPRESENTATIVE (Provide docket number or proof of appointment for any court appointed fiduciary.) Minor List age: (adjudicated or alleged) Guardian Conservator Unrepresented* Incapacitated or protected person Unborn or unascertained Minor List age: (adjudicated or alleged) Guardian Conservator Unrepresented* Incapacitated or protected person Unborn or unascertained 6. NONE of the devisees who survived the Decedent are deceased at the time of this filing except for: NAME OF SINCE DECEASED DEVISEE DATE OF DEATH NAME/ADDRESS OF REPRESENTATIVE (Provide docket number or proof of appointment for any court appointed fiduciary.) REPRESENTED BY Personal Representative (Required for an informal proceeding) Unrepresented (Formal proceeding required) Personal Representative (Required for an informal proceeding) Unrepresented (Formal proceeding required) 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 (Print name) American LegalNet, Inc. www.FormsWorkFlow.com MPC 163 (4/15/16) DEV page 2 of 2