ESTATE ADMINISTRATION INTAKE FORM   

Will attached: ____
Death Certificate attached: ____

Decedent Information:

Name: ________________________________________  SSN:___________________  Age:  _______

Address:______________________________________  Municipality: ____________________________

Date of Birth: _____________________________ Date of Death: __________________________

Place of Death:______________________________________________________________________________

Executor/Executrix Information:

1. Name:___________________________________________  SSN:_______________________________

Address:______________________________________________________________________________

Phone # ___________________

2. Name:___________________________________________  SSN:_______________________________

Address:______________________________________________________________________________

Phone # __________________

Asset Summary:

Personal Prop $__________________                 Domicile in PA: ____ yes   _____ no

PP in PA  $__________________                   

PP in County $__________________                    If No – What State? __________________

PA Real Estate $__________________ 

Real estate location (if different than decendent's address above):   

_____________________________________________________________________________________

Account Information:

Institution: _________________________________________________________________________________ 

Type of Account: ___checking ___ saving ___ CD    ___other ( ________________)

Institution: _________________________________________________________________________________ 

Type of Account: ___checking ___ saving ___ CD    ___other ( ________________)

Institution: __________________________________________________________________________________      

Type of Account: ___checking ___ saving ___ CD    ___other ( ________________)

Institution: __________________________________________________________________________________      

Type of Account: ___checking ___ saving ___ CD    ___other ( ________________)

Safe Deposit Box: (location)______________________________________________________________________

Beneficiary Information:

1. Name:______________________________                SSN:_______________ Relation:  _______

Address:________________________________________________________________   

Bequest:________________________________________________________________

2. Name:______________________________                SSN:_______________ Relation:  _______

Address:________________________________________________________________

Bequest:________________________________________________________________

3. Name:______________________________                SSN:_______________ Relation:  _______

Address:________________________________________________________________   

Bequest:________________________________________________________________

4. Name:______________________________                SSN:_______________ Relation:  _______

Address:________________________________________________________________   

Bequest:________________________________________________________________

5. Name:______________________________                SSN:_______________ Relation:  _______

Address:________________________________________________________________   

Bequest:________________________________________________________________

6.   Charitable Bequest    _____ yes _____ no

7.    If yes, is it over $25,000.00 _____ yes _____no