Free Bristol County - Massachusetts

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

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

Date of Death
(county) (zip)

Name and address of Public Administrator/Administratrix

Decedent left no known widow/widower or heir in this Commonwealth; that said decedent left property in the County of to be administered,

The petitioner is designated by the Department of Public Welfare as the Public Administrat to be appointed pursuant to M.G.L. ch. 194 specifically to pursue a claim against the estate for $ the amount alleged due the Department pursuant to M.G.L. ch. 118E. Further, the petitioner states that more than one year has passed from the date of decedent's death, and neither a petition for administration of the decedent's estate nor for admission to probate of the decedent's will has been filed with the Probate and Family Court.
,

The petitioner hereby certifies 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 01 615-9906. Petitioner prays that he/she be appointed administrator/administratrix of said estate - with - without sureties on his/her bond and certifies under the penalties of perjury that the foregoing statements are true to the best of his/her knowledge and belief. Date Signature

DECREE All persons interested having been notified in accordance with the law and no objections being made thereto, it of said estate, first giving is decreed that said Public Administrat be appointed administrat bond with sureties for the due performance of said trust.

Date Justice of the Probate and Family Court

CJ-P 9 (11/01)

bcpfc - c.g.f.

For Petitioner:

Docket No.

Public Administration
With Sureties Tel. No. ( B.B.O. # For Respondent: Filed Citation Issued Returnable Tel. No. ( B.B,O. # Publication in the , 20 , 20 , 20 , 20 Page ) Petition - Decree

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Allowed Recorded Vol.

Instructions
Refer to Massachusetts General Laws Chapter, 194, Section 1.