TO BE SUBMITTED WITH CERTIFIED DEATH CERTIFICATE, ORIGINAL WILL/CODICIL (if applicable)
Asset and Debt information are not required if there is a Will.
If there is NO WILL, please include a list of ALL Assets and Debts held in the decedent’s name alone (including
values, account numbers, VIN numbers, etc.) along with a certified Death Certificate.
Decedent’s Name:___________________________________________ A.K.A.: ______________________________
Address: ________________________________________________________________________________________
Date of Birth: ______________ Date of Death: _______________ SS#: _____________________
Is there a Will? Y___ N___ Date of Will: ________________ Codicil date (if applicable): ______________
Does the Will establish a Trust? Y___ N___ Is a Minor/Disabled Person Inheriting? Y___ N___
Executor/Administrator/Personal Representative
Name: _________________________________ Relationship to Decedent: _____________ SS#:__________________
Address:_______________________________________ City: ____________________ State:_____ Zip:__________
Telephone:_____________________________ Email:_______________________________________________
Next of Kin/Relatives Relationship to Decedent City, State Age (if Minor)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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List of Assets (Real estate, car, bank accounts, etc.): Debts (credit, medical debt, funeral bill, etc.):
________________________________ $______________ _______________________ $___________
________________________________ $______________ _______________________ $___________
________________________________ $______________ _______________________ $___________
________________________________ $______________ _______________________ $___________
________________________________ $______________ _______________________ $___________
________________________________ $______________ _______________________ $___________
________________________________ $______________ _______________________ $___________
________________________________ $______________ _______________________ $___________
Estimated Value of Estate: $____________________ Total Amount of Debts: $_________________
Attorney (if applicable)_______________________________ Address_______________________________________
Telephone ________________________ Email: _______________________________________________________
Trustee (If Will Establishes a Trust)
Trustee:___________________________________ Trustee Phone #: ______________________________
Address:___________________________________ Beneficiary:_______________________________ Age:_______
__________________________________________ Beneficiaries City, State: ________________________________
Additional Info:
_________________________________________________________________________________________________
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