Commonwealth of Massachusetts The Trial Court Probate and Family Court Department Division Docket No. Voluntary Executor/Executrix Name of Decedent Domicile at Death (Street and No.) (City or Town) (zip) (County) Date of Death Will and Death Certificate shall be filed with application. . Name and address of Applicant(s) Status Your Applicant(s) respectfully state(s) that said estate consisting 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 the assets of said deceased known to the applicant(s): Name of Property Estimated Value Total $ $ $ $ $ $ That thirty days have expired since the date of death of said deceased and no petition for probate of will or appointment of administration/administratrix has been filed in said Court. That your applicant(s) ha-undertaken to act as voluntary executor/executrix of the estate of said deceased and will administerthe same according to law and apply the proceeds thereof in conformity with Section 16A of Chapter 195 of the General Laws. That to the knowledge of the applicant(s) the following are the names and addresses of all persons surviving who, with the deceased, were joint owners of property; also listed are the names and addresses of those who would take under the provisions of Section 3 of Chapter 1 90 in the case of intestacy, and the names and addresses of those who would take under the provisions of the will. that a copy of this document, along with a copy of the decedent's death The applicant(s) hereby certif certificate has been sent by certified mail to the Division of Medical Assistance, PO Box 15205, Worcester, MA 01615. Date Signature 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, NOTARY PUBLIC / JUSTICE OF THE PEACE My Commission expires c.g.f. American LegalNet, Inc. www.FormsWorkflow.com Docket No. For Petitioner: Voluntary Executor Statement Filed 20 Attested Copy Issued 20 Recorded Vol. Page Instructions Refer to Massachusetts General Laws Chapter 195, Section 16A, as amended. Will and Death certificate must be filed with application. Give motor vehicle identification number. Status of applicant includes the following: surviving spouse, child, grandchild, parent, brother, sister, niece, nephew, aunt or uncle if of full age and legal capacity and inhabitant of the Commonwealth of Massachusetts. Notice Regarding Massachusetts Estate Taxes You may need to file a Massachusetts Estate Tax Return and a Massachusetts Fiduciary Income Tax Return, especially if the decedent owned an interest in real estate, or if the decedent had more than $1 00 of income received after the date of death. You may need to file a Massachusetts Estate Tax Return (Form M-706) in order to obtain a release of lien (Form M-792) on this real estate. You may need to file a Massachusetts Fiduciary Income Tax Return (Form 2) to report income of more than $1 00 received after the date of death. You should contact the Massachusetts Estate Tax Bureau for information and assistance regarding the estate tax law (617-727-4448) or the fiduciary income tax law (617-727-4305). American LegalNet, Inc. www.FormsWorkflow.com