Decedent’s Personal Profile
1807 Market Boulevard
PMB 335
Hastings, MN 55033
Office 651-438-3789
Fax 651-438-3936
753585v2
INDEX
I.
Decedent’s Personal and Family Information ........................................................................... 1
II. Assets .......................................................................................................................................... 6
III Life Insurance ............................................................................................................................. 10
IV.
1031417
Retirement Plan Benefits ......................................................................................................... 10
I. DECEDENT’S PERSONAL AND FAMILY INFORMATION
(Please Print)
A.
NOMINATED PERSONAL REPRESENTATIVE’S INFORMATION:
1.
2.
Your Name
Your Address
Your Social Security Number
Phone Number
E-mail Address
B.
1.
DECEDENT’S FAMILY INFORMATION:
Decedent’s Name
Social Security Number
Nickname
Birthplace
Birth Date
Was the decedent a U.S. citizen? Yes ______ No ______
If the decedent was not a U.S. citizen, was the decedent a resident or non-resident alien?
Yes ______ No ______
Circle all states in which the decedent lived: CA, WA, NY, AZ, NM, TX, ID, LA or WI
2.
Decedent’s Spouse’s Name
Social Security Number
Birth Date
Date of Death, if applicable
Is/was the decedent’s spouse a U.S. citizen? Yes ______ No ______
3.
Decedent’s Address
County of Residence at date of death
4.
Date of Death
Place of Death
PLEASE ATTACH A CERTIFIED COPY OF DECEDENT’S DEATH CERTIFICATE.
C. THE DECEDENT’S CHILDREN/GRANDCHILDREN:
Children
1. Child's Full Legal Name
Nickname
Birth Date
Social Security Number
Home Address
City
Home Phone Number
County of Residence
 Married  Divorced  Widowed  Single
1031417
State
Spouse's Name
Zip
Grandchildren's Names
Parents
Ages
√ if Deceased



2. Child's Full Legal Name
Nickname
Birth Date
Social Security Number
Home Address
City
Home Phone Number
County of Residence
 Married  Divorced  Widowed  Single
Grandchildren's Names
Parents
State
Zip
Spouse's Name
Ages
√ if Deceased



3. Child's Full Legal Name
Nickname
Birth Date
Social Security Number
Home Address
City
Home Phone Number
County of Residence
 Married  Divorced  Widowed  Single
Grandchildren's Names
Parents
State
Zip
Spouse's Name
Ages
√ if Deceased



4. Child's Full Legal Name
Nickname
Birth Date
Social Security Number
Home Address
City
Home Phone Number
County of Residence
 Married  Divorced  Widowed  Single
Grandchildren's Names
Parents
State
Zip
Spouse's Name
Ages
√ if Deceased



5. Child's Full Legal Name
Nickname
Home Address
1031417
Birth Date
Social Security Number
City
State
Zip
Home Phone Number
County of Residence
 Married  Divorced  Widowed  Single
Grandchildren's Names
Spouse's Name
Parents
Ages
√ if Deceased



6. Child's Full Legal Name
Nickname
Birth Date
Social Security Number
Home Address
City
Home Phone Number
County of Residence
 Married  Divorced  Widowed  Single
Grandchildren's Names
State
Spouse's Name
Parents
Ages
√ if Deceased



D. PREDECEASED CHILDREN:
Does the decedent have any children who are deceased?
If yes, did the decedent’s child have children?
Grandchildren's Names
1031417
Parents
Yes
Zip
Yes
No
No
Ages
II. SUMMARY OF ASSETS AND LIABILITIES
(Approximate Market Value)
A. ASSETS:
THE
DECEDENT’S
NAME ALONE
JOINT TENANACY
$
$
$
$
$
$
$
$
$
$
$
$
Cash Accounts
Investment Accounts (Annuities, IRA’s and other
retirement plan assets should be listed later)
Stocks
Bonds
Personal Effects
Retirement Plans (IRA’s, 401k accounts, etc.)
1031417
THE
DECEDENT’S
NAME ALONE
JOINT TENANACY
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Pension/Profit Sharing Plans
Life Insurance Policies
Annuities
Monies Owed to The decedent
Partnership & LLC Interests
Corporate Business Interests
Sole Proprietorship Interests
1031417
THE
DECEDENT’S
NAME ALONE
JOINT TENANACY
$
$
$
$
$
$
$
$
Oil, Gas and Mineral Interests
Anticipated Inheritance, Gift or
Lawsuit Judgment
Real Property
Other Assets
TOTAL ASSETS:
B. LIABILITIES:
THE
DECEDENT’S
NAME ALONE
JOINT
TENANCY
Mortgage on Primary Residence
$
1031417
$
THE
DECEDENT’S
NAME ALONE
JOINT
TENANCY
Mortgages on Secondary
Residence(s)
$
$
$
$
$
$
$
$
$
$
Mortgage on Other Property
Bank Loans
Margin Accounts
Other Debts, Loans, Liabilities
TOTAL LIABILITIES:
C. SUMMARY OF NET WORTH:
Total Assets:
Minus Total
Liabilities:
NET WORTH:
1031417
III.
Company
Date
of Issue
LIFE INSURANCE
Policy #
Type
*Amount
Beneficiary
DID the decedent have any outstanding loans against any of the above policies?
*As of Date of Death
(Please provide copies of beneficiary designations.)
IV.
Employer (if applicable)
Type
of Plan
RETIREMENT PLAN BENEFITS
Where
Invested
*As of Date of Death
(Please provide copies of beneficiary designations.)
1031417
*Account
Value
Primary
Beneficiary
Contingent
Beneficiary