PETITION FOR ORDER OF COMPLETE SETTLEMENT PURSUANT TO G. L. c. 190B, � 3-1001 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") makes the following statements: 1. Information about the Petitioner: Name: First Name Middle Name 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 #: Interest of the Petitioner: Personal Representative Date of appointment: Other: (relationship) 2. One year has passed since the appointment of the original Personal Representative or the Petitioner is the Personal Representative. 3. The time for presenting claims that arose prior to the Decedent's death has expired (i.e. one year from date of death; see G. L. c. 190B, � 3-803). II. PERSONS INTERESTED IN THE ESTATE 4. The names and addresses of all interested persons and their interest in the estate are as follows: NAME ADDRESS (omit if since deceased) INTEREST (e.g. heir, devisee, etc.) American LegalNet, Inc. www.FormsWorkFlow.com MPC 855 (3/1/17) page 1 of 4 ALL PETITIONERS MUST COMPLETE 5 AND 6, IF APPLICABLE 5. NONE of the interested persons listed in 4. are under a legal disability except for: NAME REPRESENTED BY LEGAL DISABILITY * (Motion and affidavit required to waive appointment of Guardian ad litem (GAL). See instructions for more information.) NAME/ADDRESS OF REPRESENTATIVE (Provide docket number or proof of appointment for any court appointed fiduciary.) Minor List age: Incapacitated Person (adjudicated or alleged) Unrepresented or only represented by the accountant (appointment of GAL requested) Independent Guardian FOR DISTRIBUTIONS PURSUANT TO � 3-915 ONLY: UTMA Custodian* (copy of proof attached) UCTA Custodian* (copy of proof attached) Agent under POA* (copy of proof attached) Protected Person (adjudicated or alleged) Independent Conservator Other as authorized by G. L. c. 190B, � 3-915*: Parent of Minor* Holder of General Power of Appointment* (copy of proof attached) Virtual Representative* (list relationship) (list relationship) Non-Accounting co-fiduciary pursuant to Uniform Practice XVIA* 6. NONE of the interested persons who survived the decedent are deceased at the time of this filing except for: NAME OF SINCE DECEASED INTERESTED PERSON DATE OF DEATH REPRESENTED BY Unrepresented (NOTE: Publication is required; Guardian ad litem may be appointed) Personal Representative NAME/ADDRESS OF REPRESENTATIVE (Provide docket number or proof of appointment for any court appointed fiduciary.) MPC 855 (3/1/17) page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com III. ALLOWANCE OF THE FINAL ACCOUNT (complete only if requesting) 7. A (specify whether 1st, 2nd, etc.) and final account is on file with the court or accompanies this Petition. IV. DETERMINATION OF TESTACY (complete only if requesting; you must also complete Section V) 8. Testacy has not been previously formally adjudicated. This Petition is filed within the time period permitted by law (G. L. c. 190B, � 3-108). Three (3) years or less have passed since the Decedent's death, or the following circumstances authorize tardy proceedings (include statutory reference): 9. 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 was informally admitted to probate on: (date) . . . The will has been probated in the state or country of An authenticated copy of the will and proof of its probate is in the possession of the court. 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. FORM ALERT: Form MPC 163 Devisees must be on file with the court or accompany this Petition. V. DETERMINATION OF HEIRS (complete only if requesting or if Section IV is completed.) 10. The heirs at law of the estate have not been previously formally adjudicated by the court. The Decedent's surviving spouse, children, heirs at law, so far as known or ascertainable with reasonable diligence by the Petitioner are as stated in the attached MPC 162 Surviving Spouse, Children, Heirs at Law dated: incorporated herein. There are additional heirs at law who are not known to the Petitioner. VI. OTHER REQUESTS AS AUTHORIZED BY G. L. c. 190B, � 3-1001 (complete only if requesting.) 11. The persons or entities entitled to distribution and the amounts to be distributed must be determined. The Petitioner proposes the following: NAME OF PROPOSED DISTRIBUTEE INTEREST PROPOSED DISTRIBUTION (date) MPC 855 (3/1/17) American LegalNet, Inc. www.FormsWorkFlow.com page 3 of 4 12. Provisions of the will which the Petitioner wants construed and the construction sought by the Petitioner are as provided in the attached statement. 13. Other (as authorized by G. L. c. 190B, � 3-1001): VII. RELIEF REQUESTED Wherefore the Petitioner requests that the court (select only as requested above): Approve the and final account(s) as filed, including the distributions stated therein, and adjudicate a final settlement of the estate. Determine testacy and the heirs at law as stated herein. Determine the heirs at law of the Decedent. Determine and approve the distribution as proposed. Construe the will as provided in the attached statement. Other: 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: American LegalNet, Inc. www.FormsWorkFlow.com MPC 855 (3/1/17) page 4 of 4