Voluntary Administration Statement {MPC 170}

VOLUNTARY ADMINISTRATION STATEMENT PURSUANT TO G. L. c. 190B, § 3-1201 Docket No. Commonwealth of Massachusetts The Trial Court Probate and Family Court Estate of: First Name Middle Name Last Name Division Date of Death: The Petitioner(s) (hereafter "Petitioner"), an interested person, makes the following statements: 1. Information about the Decedent: Name: First Name Middle Name Name Last Name Also known as: Domicile at death: (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) 2. Information about the Petitioner: Name: First Name M.I. Last Name (Address) (Apt, Unit, No. etc.) (Address) (Apt, Unit, No. etc.) (City/Town) (City/Town) (State) (State) (Zip) (Zip) Mailing Address, if different: Primary Phone #: The Petitioner's interest in the estate is as follows (e.g., Personal Representative named in a will, surviving spouse, heir, devisee, etc. See G. L. c. 190B, §§ 3-1201, 1-201(24)): 3. At least 30 days have elapsed since the death of Decedent. 4. A death certificate issued by a public officer is in the possession of the court or accompanies this statement. 5. OR The original will and codicil(s) are in the possession of the court or accompanies this statement. The Petitioner is unaware of any instrument revoking the will and believes that the will filed with this court is the decedent's last will. 6. Copies of this statement and the death certificate have been sent by certified mail to the Division of Medical Assistance, Estate Recovery Unit, P.O. Box 15205, Worcester, MA 01615-0205. 7. The probate estate consists entirely of personal property and the total value of all personal property owned by the Decedent and subject to disposition by will or intestate succession at the time of the Decedent's death does not exceed $25,000.00, exclusive of one motor vehicle. The Petitioner is unaware of any unrevoked will relating to property in Massachusetts. American LegalNet, Inc. www.FormsWorkFlow.com MPC 170 (4/15/16) page 1 of 3 Docket No. Estate of: First Name Middle Name Last Name 8. A schedule of every asset of the probate estate and the estimated value of each is as follows: Description of Property Motor vehicle make, model, VIN: Estimated Value n/a Total: 9. The following are the names and addresses of all persons who, with the deceased, were joint owners of property. Also listed are the names and addresses of those who would take in the case of intestacy and the names and addresses of those persons and/or charities who would take as devisees under the provisions of any will. Name Address Interest Heir Devisee Joint Owner Heir Devisee Joint Owner Heir Devisee Joint Owner Heir Devisee Joint Owner Heir Devisee Joint Owner 10. No petition is pending or has been granted in any jurisdiction. The undersigned understands that I/we are answerable and accountable to any subsequently appointed Personal Representative of the estate or any other person having a superior right to the estate. 11. The undersigned will act as a Voluntary Personal Representative of the probate estate of the deceased and will administer the same according to law, and apply assets of the probate estate to those persons entitled as creditors, heirs, devisees under any will, and otherwise in accordance with G. L. c. 190B, § 3-1201. American LegalNet, Inc. www.FormsWorkFlow.com MPC 170 (4/15/16) page 2 of 3 Docket No. Estate of: First Name Middle Name Last Name 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 Information on Attorney for Petitioner, if any Signature of Attorney (Print name) (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) Primary Phone #: B.B.O. # Email: (Do Not Write Below This Line-For Court Use Only) CERTIFICATION As Register of Probate having the care and custody of the records pertaining to this court, I certify that the preceding document is a true, exact, complete and unaltered copy of the Statement of Voluntary Administration filed with this court. Date Register of Probate American LegalNet, Inc. www.FormsWorkFlow.com MPC 170 (4/15/16) page 3 of 3