PERSONAL REPRESENTATIVE'S AFFIDAVIT Docket No. OF NOTICE TO CREDITORS OF REPRESENTATION OF INSOLVENCY PURSUANT TO G.L. c. 190B, § 3-807 Estate of: First Name Middle Name Last Name Commonwealth of Massachusetts The Trial Court Probate and Family Court Division Date of Death: I, First Name M.I. Last Name the Personal Representative of the above named estate, certify under the penalties of perjury that I gave notice of the filing of the within Representation of Insolvency by forwarding a copy of the same by certified, registered, or first class mail to all known creditors of said Decedent and to all other persons interested. Date: Signature of Personal Representative Signature of Co-Personal Representative Date: Signature of Attorney for Personal Representative (Print name) (Address) (City/Town) (State) (Apt, Unit, No. etc.) (Zip) Primary Phone #: B.B.O. # Email: American LegalNet, Inc. www.FormsWorkFlow.com MPC 261 (3/19/12) AFNTCCRINS