Mpc 170 Form – Fill Out and Use This PDF

VOLUNTARY ADMINISTRATION

Docket No.

Commonwealth of Massachusetts

The Trial Court

STATEMENT

Probate and Family Court

PURSUANT TO G.L. c. 190B, § 3-1201

Estate of:

Division

First Name

Middle Name

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 NameMiddle NameLast Name

Also known as:

Name

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.)

(City/Town)

(State)

(Zip)

Mailing Address, if different:

(Apt, Unit, No. etc.)

(Address)

(City/Town)

(State)

(Zip)

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.	The Petitioner is unaware of any unrevoked Will relating to property in Massachusetts.

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.

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:

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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.

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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:

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