Preview
PETITION FOR INFORMAL Docket No. Commonwealth or Massachusetts
e Trial Cour
& PROBATE OF WILL '
Probate and Family Court
{ APPOINTMENT OF PERSONAL
REPRESENTATIVE ACAI PH
PURSUANT TO G.L. c. 190B, § 3-301
Original Form (J Amended Form
Estate of:
Thomas EF. Kushi, Jr. Berkshire Division
First Name Middle Name Tast Name
Date of Death: January 16, 2021
I. GENERAL INFORMATION
The Petitioner(s) (hereafter "Petitioner"}, an interested person, makes the following statements:
1. Information about the Decedent:
Name: Thomas FL Kushi, Jr. Age atdeath 84
First Name Middle Name Tast Name.
Also known as:
Name
Street Address: 55 Roberta Road Pittsfield MA 01201
—tadgressy— init, No. ef) “__“{CityTowny SS Taley py
The Decedent was domiciled in Pittsfield MA
CityiTown) ‘ Ctaley
FORM ALERT: A death certificate issued by a public officer is in the possession of the court or accompanies this
Petition.
2. Information about the Petitioner:
Name: Thomas F. Kushi, Ill
First Name MT Last Name
626 Hancock Road Pittsfield MA 01201
(Address) Apt Unit, No. ele) (CiyTowny Tipy
Mailing Address, if different:
Tadaressy Tpt, Unit, No. etc) CciyiTowny Sratey— Zip)
Primary Phone #: 413-443-5235 Email:
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, § 1-201(24)): Personal Representative named in Will
3. This Petition is filed within the time period permitted by law (See G. L. c. 190B, § 3-108). Three years or less have passed
since the Decedent's death, or the following circumstances authorize tardy proceedings (include statutory reference):
FORM ALERT: Do not use this form to file a late probate proceeding pursuant to G. L. c. 190B, § 3-108(4). Use form
MPC 161.
4. Venue for this proceeding is proper in this county because cn the date of death, the Decedent:
[X] was domiciled in this county. [(] was not domiciled in Massachusetts, but had property located in this county at,
(20S 19
aa
TAdaressy Apr, Unt, No. etcy CityrTowny erate) Tip)
5. The Petitioner gave written notice seven (7) days prior to petitioning for informal probate or appointment by sending a
copy of this Petition and death certificate by certified mail to Division of Medical Assistance, Estate Recovery Unit,
P.O. Box 15205, Worcester, MA 01615-0205.
MPC 150 (12/11/20) page 1 of 3
\-ll. PERSONS INTERESTED IN THE ESTATE
6. The Decedent's surviving spouse, children, heirs at law and devisees (if any), so far as known or ascertainable with
reasonable diligence by the Petitioner are as stated in form MPC 162 Surviving Spouse, Children, Heirs at Law AND if
the Decedent died with a will, form MPG 163 Devisees incorporated herein.
(7 There are additional heirs at law who are not known to the Petitioner (Formal proceeding required).
FORM ALERT: Failure to submit this information will result in a delay in processing your case.
Il, TESTACY STATUS.
7. The Decedent died (select one):
CZ Intestate (without a will)
After the exercise of reasonable diligence, the Petitioner is unaware of any unrevoked testamentary instrument relating
to property in Massachusetts, or [_] see attached statement of why such an instrument is not being probated.
[| Testate (with a will)
The date of the Decedent's last will is April 23, 2018
OO The dates of all codicils are
(select one of the following):
X] The original will is in the possession of the court or accompanies this Petition.
(J The original will has been probated in Massachusetts and the Petitioner adopts the statements in the
Petition for probate.
J The original will has been probated in the state or country of
An authenticated copy of the will and proof of its probate are filed with this Petition.
The will and any codicils are referred to as the will. The Petitioner, to the best of his or her knowledge, believes the
will was validly executed. After the exercise of reasonable diligence, the Petitioner is unaware of any instrument
revoking the will and believes that the will is the Decedent's last will.
'. APPOI V
(if requested)
8. [X] The Petitioner requests that the following qualified person, who is 18 years of age or older, be appointed Personal
Representative: [X] Self only. (CO Self and other(s): [_] Other(s):
Name of other(s):
FirstName AT. Tast Name
daressy TApt Unit, No. CilyiTowny rate) Tipy
etc.)
Mailing Address, if different: )
——Raaressy TE, Unit, No- ete) ——(CiyTowny [Staley Zipp
Primary Phone #:
9, All nominees listed above have priority for appointment:
by statute. See G. L. c. 1908, § 3-203.
(11s by renunciation and/or nomination. Persons with higher or equal rights to appointment are:
FirstName MT. Last Name
FORM ALERT: All required renunciations/nominations using form MPC 455 must accompany this Petition.
MPC 150 (12/11/20) page 2 of 310. Select one of the following:
EJ] No court has appointed a Personal Representative and no such appointment proceeding is pending in
Massachusetts or elsewhere.
(J Acourt has appointed a Personal Representative, whose appointment has not been terminated, or an appointment
proceeding is pending in the State of and the Personal Representative's name and
address is:
First Name MI Last Name
TAddress) TApE Unit, No. fe) CilyTowny ®latey Zipy
11. Select one of the following:
( Abond with sureties in the penal sum amount of $ has been filed.
[1] A bond without sureties has been filed and is permissible because:
The will waives sureties on the bond and no interested person has demanded that a bond with sureties be filed.
All devisees (if a will is filed) or heirs (if no will is filed) have waived sureties in writing using form MPC 455 and
all waivers are filed with this Petition or are in the possessicn of the court.
FORM ALERT: All persons seeking appointment must file a bond using form MPC 804.
V. RELIEF REQUESTED
Wherefore, the Petitioner requests that the court/magistrate:
[x] Admit the Decedent's will to informal probate.
Appoint the nominee(s) with priority for appointment as Personal Representative of the estate in an
unsupervised administration to serve without [[] with sureties on the bond and that Letters be issued.
SIGNED UNDER THE PENALTIES OF PERJURY
| certify under the penalties of perjury that the foregoing statements are true to the best of my knowledge and belief.
Preview
PETITION FOR INFORMAL Docket No. Commonwealth or Massachusetts e Trial Cour & PROBATE OF WILL ' Probate and Family Court { APPOINTMENT OF PERSONAL REPRESENTATIVE ACAI PH PURSUANT TO G.L. c. 190B, § 3-301 Original Form (J Amended Form Estate of: Thomas EF. Kushi, Jr. Berkshire Division First Name Middle Name Tast Name Date of Death: January 16, 2021 I. GENERAL INFORMATION The Petitioner(s) (hereafter "Petitioner"}, an interested person, makes the following statements: 1. Information about the Decedent: Name: Thomas FL Kushi, Jr. Age atdeath 84 First Name Middle Name Tast Name. Also known as: Name Street Address: 55 Roberta Road Pittsfield MA 01201 —tadgressy— init, No. ef) “__“{CityTowny SS Taley py The Decedent was domiciled in Pittsfield MA CityiTown) ‘ Ctaley FORM ALERT: A death certificate issued by a public officer is in the possession of the court or accompanies this Petition. 2. Information about the Petitioner: Name: Thomas F. Kushi, Ill First Name MT Last Name 626 Hancock Road Pittsfield MA 01201 (Address) Apt Unit, No. ele) (CiyTowny Tipy Mailing Address, if different: Tadaressy Tpt, Unit, No. etc) CciyiTowny Sratey— Zip) Primary Phone #: 413-443-5235 Email: 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, § 1-201(24)): Personal Representative named in Will 3. This Petition is filed within the time period permitted by law (See G. L. c. 190B, § 3-108). Three years or less have passed since the Decedent's death, or the following circumstances authorize tardy proceedings (include statutory reference): FORM ALERT: Do not use this form to file a late probate proceeding pursuant to G. L. c. 190B, § 3-108(4). Use form MPC 161. 4. Venue for this proceeding is proper in this county because cn the date of death, the Decedent: [X] was domiciled in this county. [(] was not domiciled in Massachusetts, but had property located in this county at, (20S 19 aa TAdaressy Apr, Unt, No. etcy CityrTowny erate) Tip) 5. The Petitioner gave written notice seven (7) days prior to petitioning for informal probate or appointment by sending a copy of this Petition and death certificate by certified mail to Division of Medical Assistance, Estate Recovery Unit, P.O. Box 15205, Worcester, MA 01615-0205. MPC 150 (12/11/20) page 1 of 3 \-ll. PERSONS INTERESTED IN THE ESTATE 6. The Decedent's surviving spouse, children, heirs at law and devisees (if any), so far as known or ascertainable with reasonable diligence by the Petitioner are as stated in form MPC 162 Surviving Spouse, Children, Heirs at Law AND if the Decedent died with a will, form MPG 163 Devisees incorporated herein. (7 There are additional heirs at law who are not known to the Petitioner (Formal proceeding required). FORM ALERT: Failure to submit this information will result in a delay in processing your case. Il, TESTACY STATUS. 7. The Decedent died (select one): CZ Intestate (without a will) After the exercise of reasonable diligence, the Petitioner is unaware of any unrevoked testamentary instrument relating to property in Massachusetts, or [_] see attached statement of why such an instrument is not being probated. [| Testate (with a will) The date of the Decedent's last will is April 23, 2018 OO The dates of all codicils are (select one of the following): X] The original will is in the possession of the court or accompanies this Petition. (J The original will has been probated in Massachusetts and the Petitioner adopts the statements in the Petition for probate. J The original will has been probated in the state or country of An authenticated copy of the will and proof of its probate are filed with this Petition. The will and any codicils are referred to as the will. The Petitioner, to the best of his or her knowledge, believes the will was validly executed. After the exercise of reasonable diligence, the Petitioner is unaware of any instrument revoking the will and believes that the will is the Decedent's last will. '. APPOI V (if requested) 8. [X] The Petitioner requests that the following qualified person, who is 18 years of age or older, be appointed Personal Representative: [X] Self only. (CO Self and other(s): [_] Other(s): Name of other(s): FirstName AT. Tast Name daressy TApt Unit, No. CilyiTowny rate) Tipy etc.) Mailing Address, if different: ) ——Raaressy TE, Unit, No- ete) ——(CiyTowny [Staley Zipp Primary Phone #: 9, All nominees listed above have priority for appointment: by statute. See G. L. c. 1908, § 3-203. (11s by renunciation and/or nomination. Persons with higher or equal rights to appointment are: FirstName MT. Last Name FORM ALERT: All required renunciations/nominations using form MPC 455 must accompany this Petition. MPC 150 (12/11/20) page 2 of 310. Select one of the following: EJ] No court has appointed a Personal Representative and no such appointment proceeding is pending in Massachusetts or elsewhere. (J Acourt has appointed a Personal Representative, whose appointment has not been terminated, or an appointment proceeding is pending in the State of and the Personal Representative's name and address is: First Name MI Last Name TAddress) TApE Unit, No. fe) CilyTowny ®latey Zipy 11. Select one of the following: ( Abond with sureties in the penal sum amount of $ has been filed. [1] A bond without sureties has been filed and is permissible because: The will waives sureties on the bond and no interested person has demanded that a bond with sureties be filed. All devisees (if a will is filed) or heirs (if no will is filed) have waived sureties in writing using form MPC 455 and all waivers are filed with this Petition or are in the possessicn of the court. FORM ALERT: All persons seeking appointment must file a bond using form MPC 804. V. RELIEF REQUESTED Wherefore, the Petitioner requests that the court/magistrate: [x] Admit the Decedent's will to informal probate. Appoint the nominee(s) with priority for appointment as Personal Representative of the estate in an unsupervised administration to serve without [[] with sureties on the bond and that Letters be issued. SIGNED UNDER THE PENALTIES OF PERJURY | certify under the penalties of perjury that the foregoing statements are true to the best of my knowledge and belief.