SURVIVING SPOUSE, CHILDREN, HEIRS AT LAW 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: FORM USE: This form must be used to identify a Decedent's surviving spouse, children and heirs at law. Heirs at law are persons entitled to receive the Decedent's property under the intestacy succession laws if there is no will. For dates of death on or after March 31, 2012, the Massachusetts Uniform Probate Code, G. L. c. 190B, � 2-101, et seq., should be consulted. For deaths prior to that date, see applicable law. Instructions: Complete ALL applicable sections of this form. For step by step instructions on how to complete this form, click on the instructions link above or see Instructions MPC 958. ALL PETITIONERS MUST COMPLETE LINE 1 AND LINE 2. 1. The Decedent did not leave a surviving spouse. left a surviving spouse: ADDRESS (omit if since deceased) NAME OF SURVIVING SPOUSE 2. a. The Decedent did not have children (biological or adopted). had the following children (biological or adopted): CHILD OF SURVIVING A SPOUSE MINOR Yes Yes Yes No No No Yes Yes Yes NAME OF DECEDENT'S CHILD ADDRESS (omit if deceased) b. The surviving spouse has surviving descendants (children, grandchildren, etc.) who are not descendants of the Decedent. Complete line 3 ONLY if the Decedent left children in line 2a who are also heirs at law. 3. a. All of the children listed in 2a survived the Decedent. b. The following children listed in 2a died before the Decedent: NAME OF PREDECEASED CHILD DATE OF DEATH c. The predeceased child(ren) listed in 3b: did not leave surviving descendants (children, grandchildren, etc.) (biological or adopted). left the following surviving descendants (children, grandchildren, etc.) (biological or adopted): American LegalNet, Inc. www.FormsWorkFlow.com MPC 162 (4/15/16) SCH page 1 of 3 NAME OF SURVIVING DESCENDANT OF PREDECEASED CHILD ADDRESS (omit if since deceased) RELATIONSHIP TO DECEDENT A MINOR Yes Yes Complete line 4 ONLY if the Decedent left NO surviving descendants (children, grandchildren, etc.). Otherwise STOP and go to line 7 and line 8. 4. The Decedent did not leave a surviving parent. left a surviving parent or parents: ADDRESS (omit if since deceased) NAME OF SURVIVING PARENT(S) For deaths on or after March 31, 2012: Complete line 5 ONLY if the Decedent left NO surviving spouse, descendants (children, grandchildren, etc.) or parents. Otherwise STOP and go to line 7 and line 8. For deaths prior to March 31, 2012: Complete line 5 ONLY if the Decedent left NO surviving descendants (children, grandchildren, etc.) or parents. Otherwise STOP and go to line 7 and line 8. 5. a. The Decedent whole or half-blood): NAME OF SURVIVING SIBILING ADDRESS (omit if since deceased) A MINOR Yes Yes did not leave a surviving sibling. left the following surviving sibling(s) (biological or adopted, b. One or more of the Decedent's siblings died before the Decedent and left surviving descendants (biological or adopted): NAME OF SURVIVING DESCENDANT OF PREDECEASED SIBLING ADDRESS (omit if since deceased) RELATIONSHIP TO DECEDENT A MINOR Yes For deaths on or after March 31, 2012: Complete line 6 ONLY if the Decedent left NO surviving spouse, descendants (children, grandchildren, etc.), parents, siblings or descendants of any predeceased sibling. Otherwise STOP and go to line 7 and line 8. For deaths prior to March 31, 2012: Complete line 6 ONLY if the Decedent left NO surviving descendants (children, grandchildren, etc.), parents, siblings or descendants of any predeceased sibling. Otherwise STOP and go to line 7 and line 8. 6. List the heirs as defined by the law in effect on the Decedent's date of death. (Select one): The heirs at law are as follows: For assistance, see the Instructions and the Massachusetts Degree of Kinship Chart (MPC 960). See also line 7 and line 8. American LegalNet, Inc. www.FormsWorkFlow.com MPC 162 (4/15/16) SCH page 2 of 3 NAME OF HEIR ADDRESS (Omit if since deceased) RELATIONSHIP TO DECEDENT A MINOR Yes Yes After a reasonable diligent search, the heirs at law are unknown or unascertainable. (Requires a formal proceeding.) ALL PETITIONERS MUST COMPLETE LINE 7 AND LINE 8, if applicable. 7. NONE of the Decedent's heirs at law (surviving spouse, children, etc.) are under a legal disability except for: NAME OF HEIR AND RELATIONSHIP TO DECEDENT REPRESENTED BY LEGAL DISABILITY * (Guardian ad litem required unless waived. See Instructions) NAME/ADDRESS OF REPRESENTATIVE (Provide docket number or proof of appointment for any court appointed fiduciary.) Minor List age: (adjudicated or alleged) Guardian Conservator Unrepresented* Guardian Conservator Unrepresented* Incapacitated or protected person Minor List age: (adjudicated or alleged) Incapacitated or protected person 8. NONE of the heirs at law (surviving spouse, children, etc.) who survived the Decedent are deceased at the time of this filing except for: NAME/ADDRESS OF REPRESENTATIVE NAME OF SINCE DECEASED HEIR DATE OF REPRESENTED BY (Provide docket number or proof of AND RELATIONSHIP TO DECEDENT DEATH Personal Representative (Required for an informal proceeding) appointment for any court appointed fiduciary.) Unrepresented (Formal proceeding required) Personal Representative (Required for an informal proceeding) Unrepresented (Formal proceeding required) 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 (Print name) American LegalNet, Inc. www.FormsWorkFlow.com MPC 162 (4/15/16) SCH page 3 of 3