Probate Intake Form Hidden H2 Step 1 of 5 20% WHEN YOU HAVE COMPLETED THIS FORM, please bring it to your scheduled meeting along with a certified copy of the decedent’s death certificate. Please be sure to provide information that is accurate and complete in all respects. Decedent InformationName of Decedent(Required)Street Address, City, State, ZipCounty of ResidenceSocial Security NoDate & Place of BirthDate of Will Date of Codicil Separate Writing Found Yes No Name of Bank Where Safe Deposit Box Was Held(Required)Spouse InformationSpouse's Name(Required)Street Address, City, State, ZipDate & Place of BirthDate & Place of DeathSocial Security NumberPersonal RepresentativeName of Personal Representative(Required)Street Address, City, State, ZipSocial Security NoHome PhoneRelationship to DecedentWork PhoneChildren of Decedent and Spouse InformationChildren of Decedent and SpouseChildren of Decedent and Spouse01234Child 1NameStreet AddressCity, State, ZipDate of Birth Social Security NoChild 2NameStreet AddressCity, State, ZipDate of Birth Social Security NoChild 3NameStreet AddressCity, State, ZipDate of Birth Social Security No.Child 4NameStreet AddressCity, State, ZipDate of Birth Social Security No List any children of the Decedent who are not also children of the above-named spouseList any children of the Decedent who are not also children of the above-named spouseList children if any01234Child 1NameStreet AddressCity, State, ZipDate of Birth Social Security NoChild 2NameStreet AddressCity, State, ZipDate of Birth Social Security NoChild 3NameStreet AddressCity, State, ZipDate of Birth Social Security NoChild 4NameStreet AddressCity, State, ZipDate of Birth Social Security NoChildren of any children who died before the DecedentList childrenList children if any01234Child 1NameStreet AddressCity, State, ZipDate of Birth Social Security NoChild 2NameStreet AddressCity, State, ZipDate of Birth Social Security NoChild 3NameStreet AddressCity, State, ZipDate of Birth Social Security NoChild 4NameStreet AddressCity, State, ZipDate of Birth Social Security NoOther Beneficiaries InformationOther BeneficiariesOther Beneficiaries01234Beneficiarie 1NameStreet AddressCity, State, ZipDate of Birth Social Security NoBeneficiarie 2NameStreet AddressCity, State, ZipDate of Birth Social Security NoBeneficiarie 3NameStreet AddressCity, State, ZipDate of Birth Social Security NoBeneficiarie 4NameStreet AddressCity, State, ZipDate of Birth Social Security No Homestead InformationLegal DescriptionExact Name(s) on TitleCountyAbstract or TorrensMortgage HolderAssessor's Est. Market ValueAmount of MortgageFair Market ValueAdditional Real Estate InformationLegal DescriptionExact Name(s) on TitleCountyAbstract or TorrensMortgage HolderAssessor's Est. Market ValueAmount of MortgageFair Market ValueBusiness and Farm AssetsName of BusinessStreet Address, City, State, ZipType of BusinessApproximate Value of BusinessName of Person Operating BusinessIf farm property, please provide a list of machinery (with approximate value) livestock, crops, leases, etc. Cash & Bank Accounts InformationCash and Bank AccountsCash and Bank Accounts01234Cash and Bank Accounts 1NameName of BankAccount NoType of AccountName of Joint Owner or PODCash and Bank Accounts 2NameName of BankAccount NoType of AccountName of Joint Owner or PODCash and Bank Accounts 3NameName of BankAccount NoType of AccountName of Joint Owner or PODCash and Bank Accounts 4NameName of BankAccount NoType of AccountName of Joint Owner or POD Securities, Stocks and Bonds InformationSecurities, Stocks and BondsSecurities, Stocks and Bonds0123Securities, Stocks and Bonds 1Name of CompanyType of InvestmentTotal No. of SharesName of Joint Owner or PODValue per Share on Date of DeathSecurities, Stocks and Bonds 2Name of CompanyType of InvestmentTotal No. of SharesName of Joint Owner or PODValue per Share on Date of DeathSecurities, Stocks and Bonds 3Name of CompanyType of InvestmentTotal No. of SharesName of Joint Owner or PODValue per Share on Date of DeathInsurance InformationInsuranceInsurance012Insurance 1Name of CompanyValue of PolicyPayable to WhomInsurance 2Name of CompanyValue of PolicyPayable to WhomAutomobiles InformationAutomobilesAutomobiles012Automobile 1Make and ModelJoint OwnerYearMilesValueVINAutomobile 2Make and ModelJoint OwnerYearMilesValueVIN Personal Property InformationValue of Furniture and Household GoodsValue of Wearing Apparel and JewelryValue of Other Personal PropertyFuneral ExpensesName of Funeral HomeAmount OwedList anyone who advanced funds for funeral expensesList anyone who advanced funds for funeral expensesNameAmount Advanced Add RemoveDid Decedent receive Medical Assistance benefits?If Decedent's spouse died first, did he/she receive Medical Assistance benefits?Other Debts and ClaimsOther Debts and ClaimsOther Debts and Claims012Other Debts and Claims 1NameStreet AddressCity, State, ZipAmount of ClaimReason for ClaimOther Debts and Claims 2NameStreet AddressCity, State, ZipAmount of ClaimReason for ClaimTaxesDate real estate taxes are next dueAmount DueWhen did Decedent last file income tax returns?Did Decedent file gift tax returns for gifts made during lifetime?You can download a copy of this form by Clicking Here.
