PETITION FOR APPOINTMENT OF SPECIAL PERSONAL REPRESENTATIVE G.L. c. 190B, § 3-614 Docket No. Commonwealth of Massachusetts The Trial Court Probate and Family Court Division Estate of: First Name Middle Name Last Name Date of Death: The Petitioner(s) (hereafter "Petitioner"), an interested person, makes the following statements: 1. Information about the Decedent: Name: First Name Middle Name Name Last Name Also known as: Street Address: (Address) (Apt, Unit, No. etc.) (date) (City/Town) (State) (Zip) The Decedent died on The Decedent was domiciled in (City/Town) at the age of , years. . (State) A death certificate issued by a public officer is in the possession of the Court or accompanies this Petition. A death certificate issued by a public officer is not in the possession of the Court and does not accompany this Petition. The circumstances which make it impossible for a death certificate to be provided are (G.L. c. 190B, § 3-402(b)): 2. Information about the Petitioner: Name: First Name M.I. Last Name (Address) (Apt, Unit, No. etc.) (Address) (City/Town) (City/Town) (State) (State) (Zip) (Zip) Mailing Address, if different: (Apt, Unit, No. etc.) Primary Phone #: Interest of the Petitioner in the estate (e.g., Personal Representative named in Will, surviving spouse, heir, devisee, etc.See G.L. c. 190B § 1-201(24)): NOTICE OF HEARING This will be heard at the Probate and Family Court located at: On: Date: Time: American LegalNet, Inc. www.FormsWorkFlow.com MPC 350 (3/19/12) page 1 of 6 3. Venue for this proceeding is proper in this county because the Decedent: had his or her domicile in this county on the date of death. did not have his or her domicile in Massachusetts, but had property in this County on the date of death located at: (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) 4. No Court has appointed a Personal Representative and no such appointment proceeding is pending in this state or elsewhere. A Court has appointed a Personal Representative, whose appointment has not been terminated, or an appointment proceeding is pending in the State of name and address is: First Name (Address) M.I. (Apt, Unit, No. etc.) (City/Town) Last Name (State) (Zip) and the Personal Representative's If a court has appointed a Personal Representative, file a certified copy of the appointing document. 5. Petitioner requests appointment of a Special Personal Representative: with authority limited to conducting a search of any safe deposit box of the Decedent for his or her Will and testament in the presence of a bank officer or other disinterested person. to preserve the Decedent's estate or to secure its proper administration for the following reasons: 6. The Petitioner requests the following suitable person, who is 18 years of age or older, be appointed: Self. Other: First Name (Apt, Unit, No. etc.) M.I. (City/Town) Last Name (Address) (State) (Zip) Primary Phone #: 7. Notice has been given. No notice has been given OR shortened notice of days has been given because an emergency exists and appointment should be made forthwith. The nature of the emergency is: MPC 350 (3/19/12) page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com 8. OR A bond with sureties in the amount of $ has been or will be filed. A bond without sureties has been filed and is permissible because: The Will waives sureties on the bond and no interested person has demanded that a bond with sureties be filed. All devisees (if a Will is filed) or heirs (if no Will is filed) have waived sureties in writing and the waivers are filed with this Petition or are in the possession of the Court. The Special Personal Representative's authority will be limited to conducting a search of any safe deposit box of the Decedent for his or her last Will and testament. Other (include statutory reference): 9. Copies of this Petition and the death certificate have been sent by certified mail to the Division of Medical Assistance, Estate Recovery Unit, P.O. Box 15205, Worcester, MA 01615-0205. The Petitioner requests that the Court appoint the nominee, or some other suitable person, as Special Personal Representative to serve: without sureties on the bond. with sureties on the bond in the amount of $ the Petitioner further requests that in addition to the statutory powers, the following powers be granted: and that Letters be issued. MPC 350 (3/19/12) page 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com 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 Date: Signature of Co-Petitioner (if applicable) I assent to the foregoing Petition: Print Name Date Date Date Date Information on Attorney for Petitioner Signature of Attorney (Print name) Signature (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) Primary Phone #: B.B.O. # Email: MPC 350 (3/19/12) page 4 of 6 American LegalNet, Inc. www.FormsWorkFlow.com PETITION FOR APPOINTMENT OF SPECIAL PERSONAL REPRESENTATIVE G.L. c. 190B, § 3-614 Docket No. Commonwealth of Massachusetts The Trial Court Probate and Family Court RETURN OF SERVICE I, specified below: (name) , hereby certify that notice was given to each interested person as To: at: (address) by certified/registered mail on: first-class mail (date) hand delivery To: at: (address) by certified/registered mail on: first-class mail (date) hand delivery To: at: (address) by certified/registered mail on: first-class mail (date) hand delivery To: at: (address) by certified/registered mail on: first-class mail (date) hand delivery 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. Date Signature of Attorney for the Petitioner or Petitioner if Pro Se Signature of Attorney for the Petitioner or Petitioner if Pro Se (Address) (City/Town) (State) (Apt, Unit, No. etc.) (Zip) (Address) (City/Town) (State) (Apt, Unit, No. etc.) (Zip) Primary Phone #: B.B.O. #: Primary Phone #: B.B.O. # MPC 350 (3/19/12) page 5 of 6 American LegalNet, Inc. www.FormsWorkFlow.com