PETITION FOR LATE AND LIMITED FORMAL Docket No. TESTACY and/or APPOINTMENT PURSUANT TO G. L. c. 190B, � 3-108(4) Original Form Estate of: Amended Form Commonwealth of Massachusetts The Trial Court Probate and Family Court Division First Name Middle Name Last Name Date of Death: (Form Alert: You cannot use this form if the Decedent died prior to March 31, 2012) 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 Also known as: Street Address: (Address) (Apt, Unit, No. etc.) (date) (City/Town) (State) (Zip) The Decedent died on or AFTER MARCH 31, 2012 on The Decedent was domiciled in (City/Town) at the age of , . (State) years. 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 (See G. L. c. 190B, �� 3-402(b), 1-107): 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 has a property right in the estate of the Decedent that is the subject of this Petition or is a person having priority for appointment as Personal Representative or other fiduciary representing an interested person. The Petitioner's interest is as follows: (e.g., Personal Representative named in a will, surviving spouse, heir, devisee, etc. See G. L. c. 190B, �� 1-201(24), 3-101). 3. No original proceeding relative to the estate has occurred within the three (3) year period after the Decedent's death and a formal testacy proceeding or appointment is necessary for the limited purpose of confirming title in the successors to estate assets listed in #8 below and paying expenses of administration, if any. See G. L. c. 190B, � 3-108(4). American LegalNet, Inc. www.FormsWorkFlow.com MPC 161 (4/15/16) page 1 of 5 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) (State) (Zip) 5. The Petitioner shall give notice once by citation to the Division of Medical Assistance. To do so, the Petitioner shall send a copy of the citation when issued by the Court together with a copy of this Petition and death certificate by certified mail at least fourteen (14) days before the return day to the Division of Medical Assistance, Estate Recovery Unit, P.O. Box 15205, Worcester, MA 01615-0205. For specific details, see the citation's Order of Notice. 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. 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 see attached statement of why such an instrument is not being probated. to property in Massachusetts, or 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 is lost, destroyed or otherwise unavailable and a copy of the original will accompanies this Petition OR a statement of its contents are attached and incorporated herein. 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. ESTATE ASSETS 8. This Petition concerns the succession of the Decedent's interest in the following property: A. REAL PROPERTY (List all real estate): Description of Property Location of Property Decedent's Interest American LegalNet, Inc. www.FormsWorkFlow.com MPC 161 (4/15/16) page 2 of 5 B. PERSONAL PROPERTY (List all stocks, bonds, securities, cash and other personal property): Description of Property Location of Property Decedent's Interest 9. V. APPOINTMENT OF PERSONAL REPRESENTATIVE (if requested) The Petitioner requests that the following qualified person, who is 18 years of age or older, be appointed Personal Representative for the limited purpose of confirming title in the successors to the estate assets listed in #8 above and paying expenses of administration, if any: Self only. Name of other(s): First Name (Apt, Unit, No. etc.) (Address) (Apt, Unit, No. etc.) M.I. Last Name (State) (State) (Zip) (Zip) Self and other(s): Other(s): (Address) (City/Town) (City/Town) Mailing Address, if different: Primary Phone #: 10. Select all that apply: All or some of the nominees 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: Any required renunciations/nominations using form MPC 455 must accompany this Petition. The nominee(s) without priority for appointment are: First Name M.I. Last Name Persons with priority have failed to request appointment or to nominate the above nominee and administration is necessary. American LegalNet, Inc. www.FormsWorkFlow.com MPC 161 (4/15/16) page 3 of 5 11. Select one of the following: A bond with sureties in the penal sum amount of $ A bond without sureties has been or will be 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