Massachusetts > Statewide > Probate And Family Court > MUPC
Voluntary Administration Statement MPC 170 - Massachusetts
| Voluntary Administration Statement Form. This is a Massachusetts form and can be used in MUPC Probate And Family Court Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
VOLUNTARY ADMINISTRATION STATEMENT PURSUANT TO G.L. c. 190B, § 3-1201 Estate of: First Name Middle Name Docket No. Commonwealth of Massachusetts The Trial Court Probate and Family Court Division Last Name Date of Death: The Petitioner(s) (hereafter "Petitioner"), an interested person(s), 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 #: Relationship of the Petitioner to the Decedent (e.g., Personal Representative named in Will, surviving spouse, heir, devisee, etc.-See G.L. c. 190B § 3-1201 and § 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 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. 8. Schedule of every asset of the probate estate and the estimated value of each: MPC 170 (3/19/12) page 1 of 3 The Petitioner is unaware of any unrevoked Will relating to property in Massachusetts. American LegalNet, Inc. www.FormsWorkFlow.com 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 under the provisions of G.L. c. 190B, §§ 2-101 through 2-114 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 the 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 for the appointment of a Personal Representative 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, takers under any Will, or otherwise in accordance with G.L. c. 190B, § 3-1201. MPC 170 (3/19/12) page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 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 170 (3/19/12) page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
