On August 16, 2022 a
Devisees
was filed
involving a dispute between
Symonowicz, Kimberley A.,
and
for Estates and Administration
in the District Court of Worcester County.
Preview
Worcester Probate and Family Court
Date Filed: 8/16/2022 12:19 PM
Commonwealth of Massachusetts
Case Number:
Docket No.
DEVISEES The Trial Court
G. L. c. 190B, § 3-301 Probate and Family Court
[X] Original Form [2| Amended Form
Estate of:
Worcester Division
Donna J. Rene
First Name Middle Name Last Name
Date of Death: July 7, 2022
Form Use: This form must be used to identify a Decedent's devisees. Devisees are persons, entities, charitable
organizations, or trusts designated in a will to receive the Decedent's personal or real property. In the case of a devise to an
existing trust or trustee, or to a trustee or trust established by the will, the trust or trustee is the devisee and the beneficiaries
are not devisees. For additional information, the Massachusetts Uniform Probate Code, G. L. c.190B should be consulted.
Instructions: Complete ALL applicable sections of this form. For step by step instructions on how to complete this form,
click on the Instructions link above or see Instructions MPC 959.
ALL PETITIONERS MUST COMPLETE LINE 1 AND LINE 2.
1. The Decedent left a will dated January 21, 2022 Q The dates of all codicils are:
The will and any codicils are referred to as the will.
2. The following devisees named in the will to inherit personal or real property were living at the time of the Decedent's
death. (Note: If the devisee is a trust,
list the name of the trust and trustees. If any devisee is a charity, list the name of
the charity and provide notice to the Massachusetts Attorney General. See G. L.c. 190B and Uniform Practice XXXIV).
NAME OF DEVISEE ADDRESS (omit it since deceased) RELATIONSHIP TO DECEDENT A MINOR
14 Bel Arbor Drive
Kimberley A. Symonowicz Niece Yes
Paxton, MA 01612
101 Whitney Street Yes
Michael A. Rene Nephew
Gardner, MA 01440
3. The following devisees named in the will to inherit personal or real property were not living at the time of the
Decedent's death.
NAME OF PREDECEASED DEVISEE DATE OF DEATH RELATIONSHIP TO DECEDENT
4. If the will names one or more persons to take in place of the pre-deceased devisee, or if the anti-lapse statute (G. L. c.
1 90B, § 2-603) applies, list the contingent devisee(s). Do not include residuary devisees named elsewhere.
NAME OF CONTINGENT DEVISEE ADDRESS (omit if since deceased) RELATIONSHIP TO DECEDENT A MINOR
Yes
M PC 163 (4/15/16) DEV page 1 of 2
Worcester Probate and Family Court
Date Filed: 8/16/2022 12:19 PM
Case Number:
ALL PETITIONERS MUST COMPLETE LINE 5 AND LINE 6, if applicable.
5. NONE of the devisees are under legal disability except for:
NAME/ADDRESS OF
REPRESENTED BY
REPRESENTATIVE
* (Guardian ad litem
NAME OF DEVISEE LEGAL DISABILITY (Provide docket number or proof of
required unless waived.
appointment for any court appointed
See Instructions)
fiduciary.)
; | Minor List age: ^Guardian
Incapacitated or protected person Conservator
(adjudicated or alleged)
Unrepresented*
O Unborn or unascertained
6. NONE of the devisees who survived the Decedent are deceased at the time of this filing except for:
NAME/ADDRESS OF
NAME OF SINCE DATE OF REPRESENTATIVE
REPRESENTED BY (Provide docket number or proof of
DECEASED DEVISEE DEATH
appointment for any court appointed
fiduciary.)
Personal Representative
(Required for an informal proceeding)
Unrepresented
(Formal proceeding required)
SIGNED UNDER THE PENALTIES OF PERJURY
I certify under the penalties of perjury that the foregoing statements are true to the best of my knowledge and belief.
Date: z? |iul A2-
Signature of Petitioner
Kimberley A. Symonowicz
(Print name)
MPC 163 (4/15/16) DEV page 2 of 2
Document Filed Date
August 16, 2022
Case Filing Date
August 16, 2022
Category
Estates and Administration
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Worcester Probate and Family Court Date Filed: 8/16/2022 12:19 PM Commonwealth of Massachusetts Case Number: Docket No. DEVISEES The Trial Court G. L. c. 190B, § 3-301 Probate and Family Court [X] Original Form [2| Amended Form Estate of: Worcester Division Donna J. Rene First Name Middle Name Last Name Date of Death: July 7, 2022 Form Use: This form must be used to identify a Decedent's devisees. Devisees are persons, entities, charitable organizations, or trusts designated in a will to receive the Decedent's personal or real property. In the case of a devise to an existing trust or trustee, or to a trustee or trust established by the will, the trust or trustee is the devisee and the beneficiaries are not devisees. For additional information, the Massachusetts Uniform Probate Code, G. L. c.190B should be consulted. Instructions: Complete ALL applicable sections of this form. For step by step instructions on how to complete this form, click on the Instructions link above or see Instructions MPC 959. ALL PETITIONERS MUST COMPLETE LINE 1 AND LINE 2. 1. The Decedent left a will dated January 21, 2022 Q The dates of all codicils are: The will and any codicils are referred to as the will. 2. The following devisees named in the will to inherit personal or real property were living at the time of the Decedent's death. (Note: If the devisee is a trust, list the name of the trust and trustees. If any devisee is a charity, list the name of the charity and provide notice to the Massachusetts Attorney General. See G. L.c. 190B and Uniform Practice XXXIV). NAME OF DEVISEE ADDRESS (omit it since deceased) RELATIONSHIP TO DECEDENT A MINOR 14 Bel Arbor Drive Kimberley A. Symonowicz Niece Yes Paxton, MA 01612 101 Whitney Street Yes Michael A. Rene Nephew Gardner, MA 01440 3. The following devisees named in the will to inherit personal or real property were not living at the time of the Decedent's death. NAME OF PREDECEASED DEVISEE DATE OF DEATH RELATIONSHIP TO DECEDENT 4. If the will names one or more persons to take in place of the pre-deceased devisee, or if the anti-lapse statute (G. L. c. 1 90B, § 2-603) applies, list the contingent devisee(s). Do not include residuary devisees named elsewhere. NAME OF CONTINGENT DEVISEE ADDRESS (omit if since deceased) RELATIONSHIP TO DECEDENT A MINOR Yes M PC 163 (4/15/16) DEV page 1 of 2 Worcester Probate and Family Court Date Filed: 8/16/2022 12:19 PM Case Number: ALL PETITIONERS MUST COMPLETE LINE 5 AND LINE 6, if applicable. 5. NONE of the devisees are under legal disability except for: NAME/ADDRESS OF REPRESENTED BY REPRESENTATIVE * (Guardian ad litem NAME OF DEVISEE LEGAL DISABILITY (Provide docket number or proof of required unless waived. appointment for any court appointed See Instructions) fiduciary.) ; | Minor List age: ^Guardian Incapacitated or protected person Conservator (adjudicated or alleged) Unrepresented* O Unborn or unascertained 6. NONE of the devisees who survived the Decedent are deceased at the time of this filing except for: NAME/ADDRESS OF NAME OF SINCE DATE OF REPRESENTATIVE REPRESENTED BY (Provide docket number or proof of DECEASED DEVISEE DEATH appointment for any court appointed fiduciary.) Personal Representative (Required for an informal proceeding) Unrepresented (Formal proceeding required) SIGNED UNDER THE PENALTIES OF PERJURY I certify under the penalties of perjury that the foregoing statements are true to the best of my knowledge and belief. Date: z? |iul A2- Signature of Petitioner Kimberley A. Symonowicz (Print name) MPC 163 (4/15/16) DEV page 2 of 2