Clinical Team Report {MPC 402}

PETITION FOR ORDER OF COMPLETE SETTLEMENT OF CONSERVATOR'S FINAL ACCOUNT (G.L. c. 190B, § 5-418) OF ISSUE(S) AS STATED In the Interests of: First Name Middle Name Docket No. Commonwealth of Massachusetts The Trial Court Probate and Family Court Division Last Name The Petitioner(s) (hereafter "Petitioner") makes the following statements: 1. Information about the Petitioner: Name: First Name Middle Name Last Name (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) Primary Phone #: Interest of the Petitioner (e.g., Conservator, spouse, creditor, etc.-See G.L. c. 190B § 1-201(24)): 2. Information about the Protected Person: Name: First Name Middle Name Last Name Current Address (include name of Nursing Facility, if applicable): (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) Primary Phone #: 3. The Conservator is First Name Petitioner as follows: M.I. Last Name (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) Date of appointment of the Conservator: 4. The interested persons, addresses, and their representatives (Guardian, Conservator, etc.) are as stated in the initial Petition filed (date) AND in addition the following: OR the following: Address Name MPC 860 (5/25/12) PTNCMPSTL page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com The Petitioner requests that the Court: Consider the and final account(s) and approve said accounting(s), distribution of assets, and adjudicate a final settlement of the estate. Compel or approve the following distribution: Name of Distributee Relationship to Protected Person Share of the Estate Approve a final settlement of the estate. 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 Date: Signature of Co-Petitioner (if applicable) Information on Attorney for Petitioner Signature of Attorney (Print name) (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) Primary Phone #: B.B.O. # Email: MPC 860 (5/25/12) PTNCMPSTL page 2 of 2 www.FormsWorkFlow.com