Representation Of Insolvency {MPC 260}

Docket No. REPRESENTATION OF INSOLVENCY PURSUANT TO G.L. c. 190B, § 3-807 Estate of: First Name Middle Name Last Name Commonwealth of Massachusetts The Trial Court Probate and Family Court Division Date of Death: 1. The Personal Representative(s): Name: First Name M.I. Last Name pursuant to G.L. c. 190B, § 3-807(b), represents to the Court that the debts claimed as owed by the Decedent at the time of death, according to the list appended, amount to: Disputed by Amount of Personal Debt Representative The costs and expenses of administration, including future probable charges: The reasonable funeral expenses: The debts and taxes with preference under federal law: The reasonable and necessary medical and hospital expenses of the last illness of the Decedent, including compensation of persons attending the Decedent: The debts and taxes with preference under other laws of the commonwealth: The debts due the division of medical assistance: All other claims: Total: 2. Please explain the reason for any disputed debts listed above. Yes Yes Yes Yes Yes Yes Yes No No No No No No No 3. The estate of the Decedent known to be chargeable with the payment is as follows: Amount Real Estate not exceeding in value: Personal Estate not exceeding in value: Other estate assets outside the Commonwealth: Balance: 4. The family exemptions and allowances are: MPC 260 (3/19/12) page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 5. The Personal Representative believes that said estate will probably be insolvent, and certifies under the penalties of perjury that the above is a correct representation of the probable condition of said estate, according to the best knowledge and belief of the Personal Representative. 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 Personal Representative Date: Signature of Co-Personal Representative (if applicable) Information on Attorney for Personal Representative Signature of Attorney (Print name) (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) Primary Phone #: B.B.O. # Email: 2 2