SMALL ESTATE CLOSING STATEMENT G.L. c. 190B, § 3-1204 Estate of: First Name Middle Name Docket No. Commonwealth of Massachusetts The Trial Court Probate and Family Court Division Last Name Date of Death: The Personal Representative makes the following statements: 1. To the best of my knowledge the value of the entire estate, less liens and encumbrances, does not exceed family allowances, exempt property, costs and expenses of administration, reasonable funeral expenses, and reasonable and necessary medical and hospital expenses of the last illness of the decedent. 2. I have fully administered the estate by disbursing and distributing it to the persons entitled thereto. 3. I have sent a copy of this closing statement to all distributees of the estate and to all creditors or other claimants of whom I am aware whose claims are neither paid nor barred and have furnished a full account, in writing, of my administration to the distributees whose interests are affected. 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 Personal Representative Date: Signature of Co-Personal Representative (if applicable) Information on Attorney for Personal Representative Signature of Attorney (Print name) (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) Primary Phone #: B.B.O. # Email: If no actions or proceedings involving the Personal Representative are pending in the Court one year after the closing statement is filed, the appointment of the Personal Representative terminates. MPC 851 (3/19/12) STCLSMES page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com