(PLEASE BE SURE TO CHECK ALL appropriate boxes. If “none”, please state “NONE”. If “not applicable”, please state “NOT
APPLICABLE”. PLEASE FILL OUT COMPLETELY.)
First M. I. Last
Address:
Street Address City State Zip
Telephone:
Home Work
Email Address:
Decedent’s Personal Data: (Spouse can include a wife, husband, co-habitation
partner) Please provide the following:
First M. I. Last
First M. I. Last
Decedent’s Birthdate: Decedent’s S. S. #
Please indicate if decedent was known by any other name:
First M. I. Last
Please mark the box adjacent to decedent’s status at the time of
his/her death:
¨ Married ¨ Unmarried
¨ Divorced ¨ Widowed
¨ Other:
Decedent’s Children: Please name all children
born or adopted by decedent. (Please use
the other side of this sheet if you need more room.)
1. Name: Birthdate:
Address:
Street
Address/PO Box # City State Zip
2. Name: Birthdate:
Address:
Street
Address/PO Box # City State Zip
3. Name: Birthdate:
Address:
Street
Address/PO Box # City State Zip
4. Name: Birthdate:
Address:
Street
Address/PO Box # City State Zip
Stepchildren:
(If you need more room, please use the other side of
this sheet.)
1. Name: Birthdate:
Address:
Street
Address/PO Box # City State Zip
2. Name: Birthdate:
Address:
Street
Address/PO Box # City State Zip
3. Name: Birthdate:
Address:
Street
Address/PO Box # City State Zip
Deceased
Children: (Does decedent have any
deceased children?; If so, please list)
Decedent’s Assets: Please indicate the market value (as best you can determine) of ALL
of decedent’s “PROPERTY”, held in decedent’s name alone and/or jointly with
his/her spouse.
Parcel #1:
Owner:
Legal Description/Location (legal description can be found on a real estate deed or the Treasurer’s
tax notice):
Parcel No.:
Date Acquired:
Assessed Value on the date of death: $
Mortgage Balance on the date of
death: ($ )
Parcel #2:
Owner:
Legal Description/Location (legal description can be found on a real estate deed or the Treasurer’s
tax notice):
Parcel No.:
Date Acquired:
Assessed Value on the date of death: $
Mortgage Balance on the date of
death: ($ )
MANUFACTURED HOME(S): If decedent
owned any manufactured homes, please Describe decedent’s manufactured home(s). (list
additional manufactured homes on back of page)
1. Make/Model:
Year: Size:
Serial No. or I.D. No.:
Personal Property Tax Parcel No.:
Real Property Tax Parcel No. of property where home affixed:
Date Acquired:
Value: $
2. Make/Model:
Year: Size:
Serial No. or I.D. No.:
Personal Property Tax Parcel No.:
Real Property Tax Parcel No. of property where home affixed:
Date Acquired:
Value: $
You
will not need to list each item of personal property owned by the decedent at
his/her death. You only need to list the
collective value of all decedent’s personal property belongings including, but
not limited to, (a) furniture, (b) household goods, (c) collectibles, (d) furs,
(e) jewelry, etc.
Total value of decedent’s
personal property: $
Describe
of any and all automobiles, boats, campers, RV’s, etc. in your decedent’s name
on the date of his/her death. Please provide
for each:
Vehicles: (include cars, trucks,
motorcycles, boats, planes, recreational vehicles, etc.)
1. Make/Model:
Year: License No.:
VIN No.:
Date Acquired:
Value: $
2. Make/Model:
Year: License No.:
VIN No.:
Date Acquired:
Value: $
3. Make/Model:
Year: License No.:
VIN No.:
Date Acquired:
Value: $
BANKING ACCOUNTS:
(Please use the back of this form
or use a separate sheet for additional banking accounts.)
1. Bank:
Account #:
Balance on date of death: $
¨ Checking ¨ Savings ¨
Certificate of Deposit ¨ Other
2. Bank:
Account #:
Balance on date of death: $
¨ Checking ¨
Savings ¨
Certificate of Deposit ¨ Other
3. Bank:
Account #:
Balance on date of death: $
¨ Checking ¨
Savings ¨
Certificate of Deposit ¨ Other
4. Bank:
Account #:
Balance on date of death: $
¨ Checking ¨
Savings ¨
Certificate of Deposit ¨ Other
1. Account Name/Description:
Account No.:
Date Acquired: Value $
2. Account Name:
Account No.:
Date Acquired: Value $
3. Account Name:
Account No.:
Date Acquired: Value $
STOCKS AND BONDS (Please use
the back of this form or use a separate sheet for additional Stocks or Bonds.)
1. Description/Company:
Account #:
No of Shares: Date Acquired:
Value: $
2. Description/Company:
Account #:
No of Shares: Date Acquired:
Value: $
3. Description/Company:
Account #:
No of Shares: Date Acquired:
Value: $
4. Description/Company:
Account #:
No of Shares: Date Acquired:
Value: $
Name
of business:
Years
in operation:
Net
Value of Business Assets:
Are there any life insurance
policies in existence on the decedent’s life? ¨ Yes ¨ No
a. Name of Company(ies):
b. Type of Insurance:
c. Amount and Cash Surrender Value:
d. Designated Beneficiary(ies):
a. Name of Company(ies):
b. Type of Insurance:
c. Amount and Cash Surrender Value:
d. Designated Beneficiary(ies):
a. Name of Company(ies):
b. Type of Insurance:
c. Amount and Cash Surrender Value:
d. Designated Beneficiary(ies):
a. Name of Company(ies):
b. Type of Insurance:
c. Amount and Cash Surrender Value:
d. Designated Beneficiary(ies):
Did
decedent own any real or personal property as joint tenants with third
parties? If so, please describe:
Total value of joint tenancy assets: $
MONEY OWED TO DECEDENT:
If
decedent loaned money to anyone, please provide the name, address, the total
amount loaned and the balance of the loan on the date of death. Please use the back of this form or use a separate
sheet for additional loans.
Name
of person decedent loaned to:
Amount
loaned:
Balance
Due on date of Death:
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
SPECIFIC BEQUESTS Please list the names and addresses of any
individual(s) decedent named in his/her will in which he/she left a specific
bequest to and the property being bequeathed to them below, if applicable. (Please use the other side of
this page if you need more room.)
1. Name:
Address:
Street
Address/PO Box # City State Zip
Bequest: (amount of estate or %)
2. Name:
Address:
Street
Address/PO Box # City State Zip
Bequest: (amount of estate or %)
3. Name:
Address:
Street
Address/PO Box # City State Zip
Bequest: (amount of estate or %)
1. Name:
Residing at: