Fill and Sign the Massachusetts Small Form

Small Estate Affidavit for Estates Not More Than 25,000 State of Massachusetts County of ______________ I, ____________________ (Name of Affiant) , upon being duly sworn, state on my oath that: 1. My post office address is: ___________________________________________ ______________________________________________ (i.e., where mail delivered) . 2. My residence address is: ____________________________________________ _________________________________ (street address, city, state, zip code) . 3. I am a legal successor to the decedent, ________________________ (Name of Decedent) , who resided at __________________________________________ _______________________________ (street address, city, state, zip code) , as: [ ] Surviving spouse, [ ] child, [ ] grandchild, [ ] parent, [ ] brother or sister, [ ] niece or nephew, [ ] aunt or uncle. 4. I am of full age and legal capacity as an inhabitant of the commonwealth. 5. The decedent passed from this life on ___________________ (date) . 6. The decedent’s estate consists entirely of personal property, the total value of which, including any motor vehicle of which the decedent was the owner, and other personal property, does not exceed twenty-five thousand dollars ($25,000) in value. 7. At least thirty (30) days have elapsed since the death of the decedent. 8. No petition for letters testamentary or letters of administration has been filed with the probate court of the county in which the decedent resided. 1 9. I am entitled to payment or delivery of the property hereby claimed. 10. A schedule of every asset of the estate known to me is attached as Schedule A. 11. The names and addresses of surviving joint owners of property with the deceased, know to me, if any, are as follows: (List, if any, or state none ) ___________ ______________________________________________________________________ ______________________________________________________________________ _____________________________________________________________________. 12. The names and addresses known to me of any individual who might be entitled to proceeds of the estate as a result of intestacy are as follows: (List, if any, or state none ) ________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _____________________________________________________________________. 13. The names and addresses known to me of any individual who might be entitled to proceeds of the estate under the decedent’s will are as follows: (List, if any, or state none ) ________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _____________________________________________________________________. 14. I have undertaken to act as voluntary personal representative of the estate of the deceased and will administer the same according to law, and apply the proceeds thereof in conformity with Section 3-1201 of the Massachusetts Uniform Probate Code. 15. Copies of this statement and death certificate have been sent to the division of medical assistance by certified mail. 16. A copy of the death certificate of the deceased is attached hereto. THE FOREGOING STATEMENT IS MADE UNDER THE PENALTIES OF PERJURY. ______________________ (Printed Name of Affiant) ______________________ (Signature of Affiant) SWORN to and subscribed before me, this the ____ day of _____________, 20____. 2 _____________________________ (Printed Name of Notary Public) _____________________________ (Signature of Notary Public) My Commission Expires: ___________________ Residing at: _____________________________ 3 Schedule A All Known Assets of the Estate Description of Asset Estimated Value _____________________________________________ ________________ _____________________________________________ ________________ _____________________________________________ ________________ _____________________________________________ ________________ _____________________________________________ ________________ _____________________________________________ ________________ _____________________________________________ ________________ Total ________________ 4