Commonwealth of Massachusetts The Trial Court Probate and Family Court Department Division Docket No. Voluntary Administration Name of Deceased Date of Death Domicile at Death (street address) (zip) (city or town) Name and address of Petitioner(s) Print Name of Petitioner(s) Relationship to Deceased Residence The petitioner(s) respectfully state(s): That thirty days have expired since the date of death of the deceased, and no petition for probate of will or appointment of administrator/trix has been filed in the Court; That petitioner(s) has/have undertaken to act as voluntary administrator/trix of the estate of the deceased and will administer the same according to law, and apply the proceeds thereof in conformity with Section 16 of Chapter 195 of the General Laws; and, That this estate consists entirely of personal property, the total value of which does not exceed fifteen thousand dollars ($15,000) exclusive of the decedent's automobile, as shown by the following schedule of all assets of the deceased known to the petitioner(s): Description of Personal Property Name of Joint Owner, if any Estimated Value Motor Vehicle Identification Number (VIN): Total: See attachment for additional property The names and addresses of those who would take under the provisions of Section 3 of Chapter 190 in the case of intestacy are: Heirs at law or next of kin of deceased including surviving spouse: Spouse: Print Name Residence American LegalNet, Inc. www.FormsWorkFlow.com CJ-P 7 (1/10) Name(s) of child(ren) including child(ren) of a predeceased child, or if none, parent(s) or if none, sibling(s), or if none, heirs or presumptive: Print Name Relationship to Deceased Residence The petitioner(s) hereby certify/ies that a copy of this document, along with a copy of the death certificate of the deceased has been sent by certified mail to MassHealth, P.O. Box 15205, Worcester, Massachusetts 01615-0205 Signature(s) Date (Signature of attorney or plaintiff, if pro se) (Print name) (Street address) (City/Town) (State) (Zip) Tel. No. B.B.O. # NOTARIZATION ,SS. Date: Then personally appeared to me known and made oath that the information contained in the foregoing statement is true to the best of his/her/their knowledge and belief. Before me, Signature of Notary Public/Justice of the Peace Print Name of Notary Public/Justice of the Peace My Commission expires CERTIFICATION Dated: I, the undersigned, HEREBY CERTIFY, that I am the Register of Probate of the Division, of the Trial Court Department, Commonwealth of Massachusetts; that as such I have custody of the records of said Court; I do FURTHER CERTIFY that the foregoing is a photographic copy of a Voluntary Administration - Executor and that said applicant is duly authorized to act as said Voluntary Administrator - Executor, and that said authority remains in full force and effect. Witness, my hand and seal of the Probate & Family Court Department of the Commonwealth of Massachusetts at . Register of Probate CJ-P 7 (1/10) American LegalNet, Inc. www.FormsWorkFlow.com