Free Hampshire County - Massachusetts

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

Administration With/Without Sureties
Name of Decedent Domicile at Death
(County) (Street and No.) (City or Town)

Date of Death
(zip)

Name and address of Petitioner(s) Status Heirs at law or next of kin of deceased including surviving spouse: Name Residence (minors and incompetents must be so designated) Relationship

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) pray(s) that he/she/they or some other suitable person of in the County of be appointed of said estate with/without surety on his/her/their bond(s) and certif administrat under the penalties of perjury that the foregoing statements 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 of be appointed administrat of said estate first giving bond County of with sureties for the due performance of said trust. Date
CJ-P1 (11/01) JUSTICE OF THE PROBATE AND FAMILY COURT

hcpfc-c.g.f.

For Petitioner:

Docket No.

Administration
Tel. No. ( B.B.0 # For Respondent: ) Filed Citation Issued Returnable Allowed Tel. No. ( B.B.0 # Publication in the ) Recorded Vol. Page With/Without Sureties Petition - Decree ,20 ,20 ,20 ,20

Instructions
Refer to Massachusetts General Laws Chapter 193, Section 1. 1. Assents of all persons required for filing Administrations Without Sureties. 2. Petitioner must be a party in interest or have assent of at least one interested person for filing with sureties. 3. Certified copy of appointment of a fiduciary is required if appointment is not in same Court. 4. Strike words ''or some other suitable person '' this is a petition for Administration Without Sureties.