Probate Questionnaire

1.
NAME OF DECEDENT:

First

Middle

Last
BIRTH DATE:

MM slash DD slash YYYY
DATE OF DEATH:

MM slash DD slash YYYY
PERMANENT RESIDENCE AT TIME OF DEATH (Prior to Nursing Home or Hospital):

Street Address

Address Line 2

City

State

ZIP Code
County of Residence:
WAS DECEDENT EVER ON MEDICAID?
- YES
- NO
WAS DECEDENT EVER ON MEDICARE?
- YES
- NO
2.
LOCATION OF WILL, IF ANY:
DATE OF WILL:

MM slash DD slash YYYY
LOCATION OF CODICIL(S), IF ANY:
DATE OF CODICIL:

MM slash DD slash YYYY
3.
PERSONAL REPRESENTATIVE (NAMED IN WILL OR PROPOSED):

First

Middle

Last
ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
DATE OF BIRTH:

MM slash DD slash YYYY
PHONE:
RELATIONSHIP TO DECEDENT:
EMAIL:
ALTERNATE PERSONAL REPRESENTATIVE (NAMED OR PROPOSED):

First

Middle

Last
ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
DATE OF BIRTH:

MM slash DD slash YYYY
PHONE:
RELATIONSHIP TO DECEDENT:
EMAIL:
4.
LOCATION OF TRUST, IF ANY:
DATE OF TRUST:

MM slash DD slash YYYY
LOCATION OF AMENDMENT(S), IF ANY:
DATE OF AMENDMENT(S):

MM slash DD slash YYYY
5.
SUCCESSOR TRUSTEE (NAMED IN TRUST OR PROPOSED):

First

Middle

Last
ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
DATE OF BIRTH:

MM slash DD slash YYYY
TELEPHONE:
RELATIONSHIP TO DECEDENT:
6. BENEFICIARIES OR HEIRS AT LAW:
DECEDENT'S SPOUSE:

First

Middle

Last
ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
TELEPHONE:
DATE OF BIRTH:

MM slash DD slash YYYY
EMAIL:
DECEDENT'S CHILDREN:
CHILD # 1:

First

Middle

Last
DATE OF BIRTH:

MM slash DD slash YYYY
ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
PHONE:
EMAIL:
CHILD # 2:

First

Middle

Last
DATE OF BIRTH:

MM slash DD slash YYYY
ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
PHONE:
EMAIL:
CHILD # 3:

First

Middle

Last
DATE OF BIRTH:

MM slash DD slash YYYY
ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
PHONE:
EMAIL:
CHILD # 4:

First

Middle

Last
DATE OF BIRTH:

MM slash DD slash YYYY
ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
PHONE:
EMAIL:
CHILD # 5:

First

Middle

Last
DATE OF BIRTH:

MM slash DD slash YYYY
ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
PHONE:
EMAIL:
OTHER BENEFICIARIES (INCLUDE LIVING SIBLINGS AND LIVING PARENTS):
NAME:

First

Middle

Last
ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
PHONE:
RELATIONSHIP TO THE DECEDENT:
DATE OF BIRTH:

MM slash DD slash YYYY
EMAIL:
NAME #2:

First

Middle

Last
ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
PHONE:
RELATIONSHIP TO DECEDENT:
DATE OF BIRTH:

MM slash DD slash YYYY
EMAIL:
NAME #3:

First

Middle

Last
ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
PHONE:
RELATIONSHIP TO DECEDENT:
DATE OF BIRTH:

MM slash DD slash YYYY
EMAIL:
7. CERTIFIED PUBLIC ACCOUNTANT (CPA):
CPA NAME:

First

Middle

Last
PHONE:
ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
8. ASSETS:
SAFE DEPOSIT BOX:
- YES
- NO
LOCATION:
DIGITIAL ASSETS:
- YES
- NO
A digital asset is digitally stored content or an online account owned by an individual.
Digital content includes individual files such as images, photos, videos, and text files. It also includes other digital content (perhaps as data in a database). These assets are stored either on a device owned by an individual (“locally”) or on devices accessed via the Internet (“in the cloud”), often as part of a service offered by a third party and governed by a contact with the individual. Some online accounts can be considered assets in and of themselves and have value to an estate. There are email accounts, social media profiles (such as YouTube or Flickr), social networking profiles (such as Facebook), and many others. These are also governed by a contact between the service provider and the individual.
DIGITIAL ASSET: TYPE/NAME:
DATE OF DEATH VALUE:
DIGITIAL ASSET: TYPE/NAME:
DATE OF DEATH VALUE:
DIGITIAL ASSET: TYPE/NAME:
DATE OF DEATH VALUE:
REAL ESTATE ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
DATE OF DEATH VALUE:
COUNTY:
HOW TITLED:
HOMESTEAD:
- YES
- NO
REAL ESTATE ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
DATE OF DEATH VALUE:
COUNTY:
HOW TITLED:
HOMESTEAD:
- YES
- NO
REAL ESTATE ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
DATE OF DEATH VALUE:
COUNTY:
HOW TITLED:
HOMESTEAD:
- YES
- NO
STOCKS & BONDS
NAME OF COMPANY:
TYPE OF SECURITY:
HOW TITLED:
LOCATION OF CERTIFICATE:
DATE OF DEATH VALUE:
NAME OF COMPANY:
TYPE OF SECURITY:
HOW TITLED:
LOCATION OF CERTIFICATE:
DATE OF DEATH VALUE:
NAME OF COMPANY:
TYPE OF SECURITY:
HOW TITLED:
LOCATION OF CERTIFICATE:
DATE OF DEATH VALUE:
BANK ACCOUNTS
BANK NAME:
ACCOUNT NUMBER:
HOW TITLED:
DATE OF DEATH VALUE:
BANK NAME:
ACCOUNT NUMBER:
HOW TITLED:
DATE OF DEATH VALUE:
BANK NAME:
ACCOUNT NUMBER:
HOW TITLED:
DATE OF DEATH VALUE:
MONEY MARKET ACCOUNTS OR CERTIFICATES OF DEPOSIT:
NAME OF INSTITUTION:
ACCOUNT NUMBER:
HOW TITLED:
DATE OF DEATH VALUE:
NAME OF INSTITUTION:
ACCOUNT NUMBER:
HOW TITLED:
DATE OF DEATH VALUE:
NAME OF INSTITUTION:
ACCOUNT NUMBER:
HOW TITLED:
DATE OF DEATH VALUE:
U.S. GOVERNMENT SAVINGS BONDS (E, EE, H):
HOW TITLED:
LOCATION OF BONDS:
TO BE CASHED:
- YES
- NO
IF YES, NAME OF TRANSFEREE:
DATE OF DEATH VALUE:
MORTGAGES AND NOTES (RECEIVABLE):
MORTGAGOR 1:
ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
TERMS OF OBLIGATION:
DATE OF DEATH VALUE:
MORTGAGOR 2:
ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
TERMS OF OBLIGATION:
DATE OF DEATH VALUE:
INSURANCE ON DECEDENT'S LIFE:
COMPANY NAME:
POLICY #:
BENEFICIARIES NAMED:
LOCATION OF POLICY:
DATE OF DEATH VALUE:
COMPANY NAME:
POLICY #:
BENEFICIARIES NAMED:
LOCATION OF POLICY:
DATE OF DEATH VALUE:
COMPANY NAME:
POLICY #:
BENEFICIARIES NAMED:
LOCATION OF POLICY:
DATE OF DEATH VALUE:
ANNUITIES:
COMPANY NAME:
POLICY #:
BENEFICIARIES NAMED:
LOCATION OF POLICY:
DATE OF DEATH VALUE:
COMPANY NAME:
POLICY #:
BENEFICIARIES NAMED:
LOCATION OF POLICY:
DATE OF DEATH VALUE:
COMPANY NAME:
POLICY #:
BENEFICIARIES NAMED:
LOCATION OF POLICY:
DATE OF DEATH VALUE:
VEHICLES
MODEL:
YEAR:
MILES:
HOW TITLED:
LOCATION OF TITLE:
CONDITION:
DATE OF DEATH VALUE:
MODEL:
YEAR:
MILES:
HOW TITLED:
LOCATION OF TITLE:
CONDITION:
DATE OF DEATH VALUE:
MODEL:
YEAR:
MILES:
HOW TITLED:
LOCATION OF TITLE:
CONDITION:
DATE OF DEATH VALUE:
MISCELLANEOUS PERSONAL PROPERTY:
9. DEBTS:

Please list all debts owed by the decedent, including the amount owed at the time of their death. (Example of debts would be credit cards, automobile loans, home loans, doctor’s bills, etc.)
CREDITOR:
ACCOUNT #:
CREDITOR’S ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
TYPE OF DEBT:
AMOUNT OWED: $
CREDITOR:
ACCOUNT #:
CREDITOR’S ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
TYPE OF DEBT:
AMOUNT OWED: $
CREDITOR:
ACCOUNT #:
CREDITOR’S ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
TYPE OF DEBT:
AMOUNT OWED: $
CREDITOR:
ACCOUNT #:
CREDITOR’S ADDRESS:

Street Address

Address Line 2

City

State

ZIP Code
TYPE OF DEBT:
AMOUNT OWED: $
10. OTHER QUESTIONS:
ARE ANY OF DECEDENT’S CHILDREN DISABLED?
- YES
- NO
IF YES, PLEASE LIST THE CHILD’S NAME AND NATURE OF DISABILITY:
HAVE ANY PROBATE PROCEEDINGS BEEN FILED?
- YES
- NO
IF YES, PLEASE LIST THE COUNTY, STATE:
11. DOCUMENTS NEEDED BY THIS OFFICE:
GENERAL:
- DEATH CERTIFICATE (WITHOUT CAUSE OF DEATH)
- COPY OF PAID FUNERAL BILL WITH PROOF OF PAYMENT
- COPIES OF ANY REAL ESTATE DEEDS
- COPIES OF ANY VEHICLE TITLES
- COPIES OF ANY BILLS
- LAST WILL AND TESTAMENT AND ANY CODICIL(S) (IF ONE EXISTS)
ORIGINAL NEEDED:
- COPY OF TRUST DOCUMENT AND ANY AMENDMENT(S) (IF ONE EXISTS)
- COPIES OF ASSETS (BANK STATEMENTS, STOCK CERTIFICATES, ETC.)
PERSONAL REPRESENTATIVE:
1) HAS APPLICANT EVER BEEN CHARGED WITH, ARRESTED FOR OR CONVICTED OF A FELONY?
- YES
- NO
IF “YES” WAS ANSWERED, PLEASE GIVE DATE AND COMPLETE DETAILS:
2) HAS APPLICANT EVER BEEN CHARGED WITH, ARRESTED FOR OR CONVICTED OF ANY OTHER CRIMES?
- YES
- NO
IF “YES” WAS ANSWERED, PLEASE GIVE DATE AND COMPLETE DETAILS:
3) DOES APPLICANT HAVE ANY PHYSICAL DISABILITES?
IF “YES” WAS ANSWERED, PLEASE EXPLAIN:
4) WILL ANY PHYSICAL DISABILITY LISTED ABOVE AFFECT ABILITY TO SERVE AS PERSONAL REPRESENTATIVE?
5) HAS APPLICANT EVER BEEN TREATED FOR THE FOLLOWING?
- Mental Condition
- Alcohol
- Drugs
- Other
NATURE OF CONDITION:
UNDER PENALTY OF PERJURY, I SWEAR OR AFFIRM THAT THE INFORMATION PROVIDED IS TRUE AND ACCURATE TO THE BEST OF MY INFORMATION AND BELIEF.
DATED THIS DAY OF:

MM slash DD slash YYYY
PRINT NAME:

First

Middle

Last

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Probate Questionnaire

1.

2.

3.

4.

5.

6. BENEFICIARIES OR HEIRS AT LAW:

DECEDENT'S CHILDREN:

OTHER BENEFICIARIES (INCLUDE LIVING SIBLINGS AND LIVING PARENTS):

7. CERTIFIED PUBLIC ACCOUNTANT (CPA):

8. ASSETS:

STOCKS & BONDS

BANK ACCOUNTS

MONEY MARKET ACCOUNTS OR CERTIFICATES OF DEPOSIT:

U.S. GOVERNMENT SAVINGS BONDS (E, EE, H):

MORTGAGES AND NOTES (RECEIVABLE):

INSURANCE ON DECEDENT'S LIFE:

ANNUITIES:

VEHICLES

9. DEBTS:

10. OTHER QUESTIONS:

11. DOCUMENTS NEEDED BY THIS OFFICE:

PERSONAL REPRESENTATIVE:

UNDER PENALTY OF PERJURY, I SWEAR OR AFFIRM THAT THE INFORMATION PROVIDED IS TRUE AND ACCURATE TO THE BEST OF MY INFORMATION AND BELIEF.

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