GENERAL
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Please complete the questions below to the best of your ability. Don't worry if you don't know any answers, just skip them. When you are done, you must "click" on the "Submit" button at the bottom of this page in order for your answers to be sent.
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YOUR INFORMATION
First Name *
Last Name *
E-mail *
Secondary E-mail
Address
City
State	AL AK AR AZ CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code
Country	Abkhazia Afghanistan Aland Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Argentina Armenia Aruba United Kingdom Ascension Island Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile People's Republic of China Republic of China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Guyana Haiti Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Transnistria Pridnestrovie Puerto Rico Qatar Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
Day Phone *
Evening Phone
Cell Phone
Date of Birth	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
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DECEASED'S INFORMATION
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Deceased's Name *
Gender	Male Female
Maiden Name (if any)
Other Names (AKA)
Decedent's Home Address
City
County	Not Sure Barnstable Berkshire Bristol Dukes Essex Franklin Hampden Hampshire Middlesex Nantucket Norfolk Plymouth Suffolk Worcester
State
At the time of death or before, decedent was involved with (check all that apply):	Medicaid Medicare MassHealth Other Program State Tax Lien Federal Tax Lien Other Liens Personal Injury Case Party in a Lawsuit Unsure
Was the decedent living at home at the time of death, in a hospital, in a facility, or other. Please explain.
Date of Birth	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Date of Death
Social Security Number
Decedent was receiving Social Security payments	Yes No Not Sure
Was someone else responsible for the deceased's death	Unsure Yes No Maybe
Marital Status at Time of Death	Married Widowed Single
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DECEASED'S SPOUSE INFO (Skip in None)
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Deceased ever married?	Don't know No Yes, Once Yes, More than Once
Spouses Name
Decedent had how many children with Spouse
Did Spouse outlive the deacesed?	Yes No Does not apply
Former Spouse(s) Names
Deceased had how many children with former Spouse(s)
If not, spouse's Date of Death
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REAL ESTATE OR PROPERTY OWNED
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Did Decedent Own Real Estate	Yes No Not sure
Addresses of any owned real estate:
Who owned the real estate	Unsure Deceased alone Deceased with living spouse Deceased with deceased spouse In a trust With another
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VEHICLE INFORMATION
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Did Decedent Own a Vehicle	Yes No Don't know
Year, Make, Model, VIN for Each:
Who owned the vehicle	Unsure Only Deceased Deceased's Spouse Deceased and Spouse Company Vehicle Leased
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PERSONAL PROPERTY AND OTHER ASSETS
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Estimated total assets (not including vehicle):	Less than $15,000 More than $15,000 Not sure
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DECEASED'S LAST WILL AND TESTAMENT
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Decedent left a Will	Yes No Don't know
Name and address of primary executor(s) named in the will
Name and address of secondary or alternate executor(s) named in the will
Do you have the original will (check all that apply)	No Yes I have a copy I know who has it I know where it is located I suspect who has it It's in a safe deposit box It's with another attorney I don't know where it is located
Was anyone left specifice gifts, bequests, or property in the will	Nut Sure Yes No
Names, addresses, phone number, and relationship of anyone named in the will who is not a spouse or child
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ASSETS AND LIABILITIES
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Check all that apply for decedent:	Had a Trust Was a Beneficiary of a Trust Made Significant Gifts Held Accounts with Someone Else Had Life Insurance Owned Property Outside of of MA Retirement account IRA Profit Sharing Annuity Union Member Employed Retired Disabled In bankruptcy Checking Account Saving Account CD Mutual Fund Stocks 403(b) Business Owner Stockholder Professional Institutionalized Has living children Has living grandchildren Has living parents Has living siblings Has living spouse Has living ex-spouse Health Insurance Medicare Medicaid Mass Health Nursing Home Assisted Living Involved in a Lawsuit or Claim
Pleae list known accounts, institutions, balances, and contact information. You may want to upload an Excel spreadsheet instead. Partial information is fine.
Please list known expenses, bills, or liabilities with the same information as requested above.
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Anything Else
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Is there anything else you would like us to know or you have questions about?
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DISCLAIMER
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The use of this form does not create any attorney-client relationship and you will not be our client unless we have agreed to represent you in writing. This form may be considered an attorney advertisement under Massachusetts law or rules for attorneys. This site is only intended for parties with probate matters involving Massachusetts cases or matters. Communications over the internet are susceptible to incorrect handling and also raise significant privacy concerns. If you are not comfortable with the risk assumed by using this site or the internet or electronic communications, do not use this form or hit submit. This form is not submitted by a secure connection and is handled by a third party who sends the data to our law office.
I have read and understand the above disclaimer. *	Yes