DOMICILIARY FOREIGN PERSONAL REPRESENTATIVE'S SWORN STATEMENT Estate of: First Name Middle Name Docket No. Commonwealth of Massachusetts The Trial Court Probate and Family Court Division Last Name Date of Death: 1. Information about the Domiciliary Foreign Personal Representative(s)(hereafter "Domiciliary Foreign Personal Representative"): Name: First Name M.I. Last Name (Address) (Apt, Unit, No. etc.) (Address) (Apt, Unit, No. etc.) (City/Town) (City/Town) (State) (State) (Zip) (Zip) Mailing Address, if different: Primary Phone #: 2. Information about the Decedent: Name: First Name Middle Name Name Last Name Also known as: click to add Alias Street Address: (Address) (Apt, Unit, No. etc.) (date) (City/Town) (State) (Zip) click to remove The Decedent died on The Decedent was domiciled in (City/Town) at the age of , years. . (State) 3. 12 months preceding death, the Decedent had a permanent or temporary abode in this County. Decedent owned tangible personal property in this County at the time of death. 4. The Domiciliary Foreign Personal Representative (G.L. c. 190B, �1-202(17)) states that no administration, or application, or Petition is pending in Massachusetts and hereby files with this Court authenticated copies of the foreign Court's Order appointing me as Fiduciary and any official bond given. MPC 180 (3/19/12) American LegalNet, Inc. www.FormsWorkFlow.com page 1 of 2 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 Domiciliary Foreign Personal Representative Date: Signature of Co-Domiciliary Foreign Personal Representative (if applicable) Information on Attorney Signature of Attorney (Print name) (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) Primary Phone #: B.B.O. # Email: MPC 180 (3/19/12) American LegalNet, Inc. www.FormsWorkFlow.com page 2 of 2