Free Hampshire County - Massachusetts

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

Appointment of Agent
I,
(City or Town)

of
(Street and No.)

appoint
(County) (State) (Zjp)

of
(Street and No.) (City or Town) (county) (zip)

as my agent and I do stipulate and agree that the service of any legal process against me as administrator/ administratrix--.executor/executrix-trustee-of the estate of late of
(Street and No.) (City or Town) (County) (ZIP)

or as guardian/conservator of of
(Street and No.) (City or Town) (county) (zip)

or against me in my individual capacity of any action founded upon or arising out of my acts or omissions as such fiduciary if made on said agent, shall have like effect as if made on me personally within said Commonwealth.

Date

Signature

Signed in the presence of

WITNESS

Acceptance 1,
(Street and No.) (City or Town)

accept the above appointment.
(state)

(ZIP)

Date

Signature

CJ-P17 (5/97)

hcpfc - c.g.f.