PETITION FOR INFORMAL PROBATE OF WILL APPOINTMENT OF PERSONAL REPRESENTATIVE PURSUANT TO G.L. c. 190B, § 3-301 Original Form Estate of: Amended Form Docket No. Commonwealth of Massachusetts The Trial Court Probate and Family Court Division First Name Middle Name Last Name Date of Death: I. GENERAL INFORMATION 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 Age at death Also known as: Street Address: (Address) (Apt, Unit, No. etc.) (City/Town) (City/Town) (State) (Zip) The Decedent was domiciled in , . (State) FORM ALERT: A death certificate issued by a public officer is in the possession of the court or accompanies this Petition. 2. Information about the Petitioner: 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 #: The Petitioner's interest in the estate is as follows (e.g., Personal Representative named in a will, surviving spouse, heir, devisee, etc. See G. L. c. 190B, § 1-201(24)): 3. This Petition is filed within the time period permitted by law (See G. L. c. 190B, § 3-108). Three years or less have passed since the Decedent's death, or the following circumstances authorize tardy proceedings (include statutory reference): FORM ALERT: Do not use this form to file a late probate proceeding pursuant to G. L. c. 190B, § 3-108(4). Use form MPC 161. 4. Venue for this proceeding is proper in this county because on the date of death, the Decedent: was domiciled in this county. (Address) was not domiciled in Massachusetts, but had property located in this county at: (Apt, Unit, No. etc.) (City/Town) American LegalNet, Inc. www.FormsWorkFlow.com (State) (Zip) MPC 150 (4/15/16) page 1 of 3 5. The Petitioner gave written notice seven (7) days prior to petitioning for informal probate or appointment by sending a copy of this Petition and death certificate by certified mail to Division of Medical Assistance, Estate Recovery Unit, P.O. Box 15205, Worcester, MA 01615-0205. II. PERSONS INTERESTED IN THE ESTATE 6. The Decedent's surviving spouse, children, heirs at law and devisees (if any), so far as known or ascertainable with reasonable diligence by the Petitioner are as stated in form MPC 162 Surviving Spouse, Children, Heirs at Law AND if the Decedent died with a will, form MPC 163 Devisees incorporated herein. There are additional heirs at law who are not known to the Petitioner (Formal proceeding required). FORM ALERT: Failure to submit this information will result in a delay in processing your case. III. TESTACY STATUS 7. The Decedent died (select one): Intestate (without a will) After the exercise of reasonable diligence, the Petitioner is unaware of any unrevoked testamentary instrument relating to property in Massachusetts, or see attached statement of why such an instrument is not being probated. Testate (with a will) The date of the Decedent's last will is The dates of all codicils are (select one of the following): The original will is in the possession of the court or accompanies this Petition. The original will has been probated in Massachusetts and the Petitioner adopts the statements in the Petition for probate. The original will has been probated in the state or country of An authenticated copy of the will and proof of its probate are filed with this Petition. The will and any codicils are referred to as the will. The Petitioner, to the best of his or her knowledge, believes the will was validly executed. After the exercise of reasonable diligence, the Petitioner is unaware of any instrument revoking the will and believes that the will is the Decedent's last will. IV. APPOINTMENT OF PERSONAL REPRESENTATIVE (if requested) 8. The Petitioner requests that the following qualified person, who is 18 years of age or older, be appointed Personal Representative: Name of other(s): First Name M.I. Last Name . . . Self only. Self and other(s): Other(s): (Address) Mailing Address, if different: (Address) (Apt, Unit, No. etc.) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) (City/Town) (State) (Zip) Primary Phone #: 9. All nominees listed above have priority for appointment: by statute. See G. L. c. 190B, § 3-203. by renunciation and/or nomination. Persons with higher or equal rights to appointment are: First Name M.I. Last Name FORM ALERT: All required renunciations/nominations using form MPC 455 must accompany this Petition. American LegalNet, Inc. www.FormsWorkFlow.com MPC 150 (4/15/16) page 2 of 3 10. Select one of the following: No court has appointed a Personal Representative and no such appointment proceeding is pending in Massachusetts 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 address is: First Name (Address) (Apt, Unit, No. etc.) M.I. (City/Town) Last Name (State) (Zip) and the Personal Representative's name and 11. Select one of the following: A bond with sureties in the penal sum amount of $ 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 using form MPC 455 and all waivers are filed with this Petition or are in the possession of the court. FORM ALERT: All persons seeking appointment must file a bond using form MPC 801. V. RELIEF REQUESTED Wherefore, the Petitioner requests that the court/magistrate: Admit the Decedent's will to informal probate. Appoint the nominee(s) with priority for appointment as Personal Representative of the estate in an unsupervised administration to serve without with sureties on the bond and that Letters be issued. has been filed. 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: MPC 150 (4/15/16) American LegalNet, Inc. www.FormsWorkFlow.com page 3 of 3