On June 21, 2021 a
Party Statement
was filed
involving a dispute between
Cormier, Christina M,
and
for Estates and Administration
in the District Court of Berkshire County.
Preview
-
/ : ~
Docket No. Commonwealth of Massachusetts
VOLUNTARY ADMINISTRATION The Trial Court
STATEMENT
MEDI POUSIEA
Probate and Family Court
PURSUANT TOG. L. c. 1908, § 3-1201
Estate of: Dek Ans TRL_ Division
Jaalith
First Name
Ann
Middle Name
RoZon
LastName
Date of Death: 3 13) | A 0a |
The Petitioner(s) (hereafter “Petitioner"), an interested person, makes the following statements:
4 Information about the Decedent:
Name: Jodivh
~ First Name Middle Name
Roe2on
Last Name
Asolnownas: adits A.Ro eon
Domicile at death: 2 CO
ress)
5S
(Apt, Uni, No. ete.)
HSE
(City/Town
eel a6 2 Tiny EO}
Information about the Petitioner:
Name: Cheistina MY Carmpec
its Lelel
First Name Cast Name
Lu Lpdlacd So
Mailing Address, if different:
TApt, Unit, No. etc.) (City/Town)
LAA
‘State) cg
(Address) Apt, Ot No. etc.) (ciyiTown) Clatey (Zip)
Primary Phone #: 13-34 9-O/EF
The Petitioner's interest in the estate is as follows (e.g., Personal Representative named in a will, surviving spouse, heir,
devisee, etc. See G.L. c. 190B, §§ 3-1201, 1-201(24)): heic
At least 30 days have elapsed since the death of Decedent.
A death certificate issued by a public officer is in the possession of the court or accompanies this statement.
yf The Petitioner is unaware of any unrevoked will relating to property in Massachusetts.
OR
CJ The original will and codicil(s) are in the possession of the court or accompanies this statement. The Petitioner is
unaware of any instrument revoking the will and believes that the will filed with this court is the decedent's last will.
Copies of this statement and the death certificate have been sent by certified mail to the Division of Medical Assistance,
=
Estate Recovery Unit, P.O. Box 15205, Worcester, MA 01615-0205.
eo
A
The probate estate consists entirely of personal property and the total value of all personal property owned by the
Decedent and subject to disposition by will or intestate succession at the time of the Decedent's death does not exceer «
$25,000.00, exclusive of one motor vehicle. mx)
,
MPC 170 (4/15/16) page 1 of 3
\
»
[Docket No.
Estate of: _ . Node
First Name
A
Middle Name
Lo2on Tast Name’
8. A schedule of every asset of the probate estate and the estimated value of each is as follows:
Description of Property Estimated Value
lotor vehicle make, model, VIN: nla
2607 Traata la mPa AT I BE tte k 1 4U 2834 ae
Y pen ZOU _@rcise tay bil\
Total:
J
9. The following are the names and addresses of all persons who, with the deceased, were joint owners of property. Also
listed are the names and addresses of those who would take in the case of intestacy and the names and addresses of
those persons and/or charities who would take as devisees under the provisions of any will.
Name Address Interest
leir
LJ Devisee
Chee rnd Bom ree lle Lallesd St Otte: HA ole) C1 Joint Owner.
I] Heir
CD Devisee
sy
C1 Joint Owner
OI Heir
Cd Devisee
(1 Joint Owner
{I
\\ OC Heir
UC Devisee
1 Joint Owner
Heir
CO Devisee
CJ Joint Owner
10. No petition is pending or has been granted in any jurisdiction. The undersigned understands that lAve are answerable
and accountable to any subsequently appointed Personal Representative of the estate or any other person having a
superior right to the estate.
11. The undersigned will act as a Voluntary Personal Representative of the probate estate of the deceased and will
administer the same according to law, and apply assets of the probate estate to those persons entitled as creditors, heirs,
devisees under any will, and otherwise in accordance with G. L. c. 190B, § 3-1201.
MPC 170 (4/15/16) page 2 of 3
Docket No.
Estate of: \. Ai
First
Wy
Name
Ann
Middle Name
12.020 Tast Name DE OIPOHADEA
SIGNED UNDER THE PENALTIES OF PERJURY
| certify under the penalties of perjury that the foregoing state!Vo are fe
true to “Crees and belief.
pate:
Document Filed Date
June 21, 2021
Case Filing Date
June 21, 2021
Category
Estates and Administration
For full print and download access, please subscribe at https://www.trellis.law/.
Preview
- / : ~ Docket No. Commonwealth of Massachusetts VOLUNTARY ADMINISTRATION The Trial Court STATEMENT MEDI POUSIEA Probate and Family Court PURSUANT TOG. L. c. 1908, § 3-1201 Estate of: Dek Ans TRL_ Division Jaalith First Name Ann Middle Name RoZon LastName Date of Death: 3 13) | A 0a | The Petitioner(s) (hereafter “Petitioner"), an interested person, makes the following statements: 4 Information about the Decedent: Name: Jodivh ~ First Name Middle Name Roe2on Last Name Asolnownas: adits A.Ro eon Domicile at death: 2 CO ress) 5S (Apt, Uni, No. ete.) HSE (City/Town eel a6 2 Tiny EO} Information about the Petitioner: Name: Cheistina MY Carmpec its Lelel First Name Cast Name Lu Lpdlacd So Mailing Address, if different: TApt, Unit, No. etc.) (City/Town) LAA ‘State) cg (Address) Apt, Ot No. etc.) (ciyiTown) Clatey (Zip) Primary Phone #: 13-34 9-O/EF The Petitioner's interest in the estate is as follows (e.g., Personal Representative named in a will, surviving spouse, heir, devisee, etc. See G.L. c. 190B, §§ 3-1201, 1-201(24)): heic At least 30 days have elapsed since the death of Decedent. A death certificate issued by a public officer is in the possession of the court or accompanies this statement. yf The Petitioner is unaware of any unrevoked will relating to property in Massachusetts. OR CJ The original will and codicil(s) are in the possession of the court or accompanies this statement. The Petitioner is unaware of any instrument revoking the will and believes that the will filed with this court is the decedent's last will. Copies of this statement and the death certificate have been sent by certified mail to the Division of Medical Assistance, = Estate Recovery Unit, P.O. Box 15205, Worcester, MA 01615-0205. eo A The probate estate consists entirely of personal property and the total value of all personal property owned by the Decedent and subject to disposition by will or intestate succession at the time of the Decedent's death does not exceer « $25,000.00, exclusive of one motor vehicle. mx) , MPC 170 (4/15/16) page 1 of 3 \ » [Docket No. Estate of: _ . Node First Name A Middle Name Lo2on Tast Name’ 8. A schedule of every asset of the probate estate and the estimated value of each is as follows: Description of Property Estimated Value lotor vehicle make, model, VIN: nla 2607 Traata la mPa AT I BE tte k 1 4U 2834 ae Y pen ZOU _@rcise tay bil\ Total: J 9. The following are the names and addresses of all persons who, with the deceased, were joint owners of property. Also listed are the names and addresses of those who would take in the case of intestacy and the names and addresses of those persons and/or charities who would take as devisees under the provisions of any will. Name Address Interest leir LJ Devisee Chee rnd Bom ree lle Lallesd St Otte: HA ole) C1 Joint Owner. I] Heir CD Devisee sy C1 Joint Owner OI Heir Cd Devisee (1 Joint Owner {I \\ OC Heir UC Devisee 1 Joint Owner Heir CO Devisee CJ Joint Owner 10. No petition is pending or has been granted in any jurisdiction. The undersigned understands that lAve are answerable and accountable to any subsequently appointed Personal Representative of the estate or any other person having a superior right to the estate. 11. The undersigned will act as a Voluntary Personal Representative of the probate estate of the deceased and will administer the same according to law, and apply assets of the probate estate to those persons entitled as creditors, heirs, devisees under any will, and otherwise in accordance with G. L. c. 190B, § 3-1201. MPC 170 (4/15/16) page 2 of 3 Docket No. Estate of: \. Ai First Wy Name Ann Middle Name 12.020 Tast Name DE OIPOHADEA SIGNED UNDER THE PENALTIES OF PERJURY | certify under the penalties of perjury that the foregoing state!Vo are fe true to “Crees and belief. pate: