Commonwealth of Massachusetts Division The Trial Court Probate and Family Court Department Docket No. Special Administration Name of Decedent Domicile at Death (street and no.) (city or town) Date of Death (county) (zip) Name and address of Petitioner(s) Status Respectfully represent(s) that said decedent died possessed of goods and estate remaining to be administered, and that there is delay in securing the appointment of of the estate of said decedent by reason of that a copy of this document, along with a copy of the decedent's death The petitioner(s) hereby certif certificate has been sent by certified mail to: The Division of Medical Assistance, P.O. Box 15205, Worcester, Massachusetts 01615. Wherefore your petitioner(s) pray(s) that he/she/they or some other suitable person: of (street and no.) may be appointed special (city or town) (county) (zip) administrator/administratrix of said decedent and may be authorized to take charge of all the real estate of said decedent and to collect rents and make necessary repairs; and may be authorized to continue the business of the decedent for the benefit of his/her estate, and certif under the penalties of perjury that the statements herein contained are true to the best of his/her/their knowledge and belief. Date Signature The undersigned hereby assent to the foregoing petition. DECREE All persons interested having been notified in accordance with the law or having assented and no objections being made thereto, it is decreed that of in the County of administrat of said estate, first giving bond with be appointed sureties, for the due performance of said trust. Date Justice of the Probate and Family Court c.g.f. American LegalNet, Inc. www.FormsWorkflow.com For Petitioner: Docket No. Special Administration Tel No. Petition - Decree Filed 20 Citation Issued 20 Returnable 20 Tel. No. Allowed 20 Publication in the Recorded Vol. For Respondent: Page Instructions Refer to Massachusetts General Laws Chapter 193, Section 10. American LegalNet, Inc. www.FormsWorkflow.com