Free Bristol County - Massachusetts

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

Administration De Bonis Non With The Will Annexed - With - Without - Sureties
Name of Decedent Domicile at Death
(street and no.) (city or town)

Date of Death
(County) (zip)

Will allowed
(date)

Name and address of executor/executrix appointed

Name and address of Petitioner(s) Status 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. Petitioner(s) represent(s) that said executor/executrix has -died -resigned -become incapacitated - without having fully executed said will and pray(s) that he/she/they or some other suitable peron of
(street and no.) (city or town) (county) (zip)

be appointed administrator/administratrix with the will annexed of the estate not already administered -withwithout - sureties on his/her/their bond 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 Signature(s)

The undersigned hereby assent to the foregoing petition.

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 of be appointed

administrator/administratrix with the will annexed of said estate not already administered, first giving bond, with sureties, for the due performance of said trust. Date
JUSTICE OF THE PROBATE AND FAMILY COURT CJ-P 4 (I 1/01)

bcpfc - c.g.f.

For Petitioner:

Docket No.

Administration De Bonis Non
Tel. No. ( B.B.O. # )

With The Will Annexed
With/Without Sureties Petition - Decree

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

Instructions Refer to Massachusetts General Laws Chapter 193, Section 9.