Free Hampshire County - Massachusetts

Commonwealth of Massachusetts
Hampshire Division The Trial Court Probate and Family Court Department Docket No.

Special Administration
Name of Decedent Domicile at Death
(street and no.) (city or town)

Date of Death
(county) (zip)

Name and address of Petitioner(s) Status Respectfully represent(s) that said decedent died possessed of goods and estate remaining to be administered, and that there is delay in securing the appointment of of the estate of said decedent by reason of

The petitioner(s) hereby certif that a copy of this document, along with a copy of the decedent's death certificate has been sent by certified mail to the Division of Medical Assistance, P.O. Box 15205, Worcester, Massachusetts 01615-9906. Wherefore your petitioner(s) pray(s) that he/she/they or some other suitable person: of
(street and no.)

may be appointed special
(city or town) (county) (zip)

administrator/administratrix of said decedent and may be authorized to take charge of all the real estate of said decedent and to collect rents and make necessary repairs; and may be authorized to continue the business of the decedent for the benefit of his/her estate, and certif under the penalties of perjury that the statements herein contained are true to the best of his/her/their knowledge and belief. Date The undersigned hereby assent to the foregoing petition. Signature

DECREE
All persons interested having been notified in accordance with the law or having assented and no objections being made thereto, it is decreed that in the County of administrat trust. Date Justice of the Probate and Family Court
CJ-P 8 (11/01)

of be appointed sureties, for the due performance of said

of said estate, first giving bond with

hcpfc - c.g.f.

For Petitioner:

Docket No.

Special Administration
Petition - Decree Tel. No. ( B.B.O. # For Respondent: ) Filed Citation Issued Returnable Allowed Tel. No. ( B.B.0 # Publication in the ) Recorded Vol. Page ,20 ,20 ,20 ,20

Instructions
Refer to Massachusetts General Laws Chapter 193, Section I 0.