San Luis Obispo — Public administrator referral form

Source: https://www.slocounty.ca.gov/departments/auditor-controller-treasurer-tax-collector-public-/forms-documents/public-administrator/public-administrator-referral-form

COUNTY OF SAN LUIS OBISPO PUBLIC ADMINISTRATOR James W. Hamilton, CPA Public Administrator Laura Mullis Deputy Public Administrator

San Luis Obispo County Public Administrator: Intake Referral Form

Name of Decedent: Social Security No.:

Referring Party: Phone/Fax:

Date of Birth: Place: Citizen: (y/n) Veteran: (y/n)

Date of Death: Place: Cause of Death:

If hospitalized, date admitted, how arrived, from where:

Mortuary/Contact: Phone/Fax:

Bank Accounts (branch/type/account #/amount):

Safe Deposit Box: (y/n) Will/Trust: (y/n) Executor:

Last Known Residence:

Landlord: Phone:

Personal Property: Location:

Real Property: Location:

Marital Status: Spouse/Children:

Mother/Father/Places of Birth:

CONTACTS (family, neighbors, friends, informants, etc) - Please provide ANY information, even if incomplete.

Name/Relationship: Phone:

Address:

Name/Relationship: Phone:

Address:

Name/Relationship: Phone:

Address:

ADDITIONAL INFORMATION/COMMENTS- Please use additional pages as needed.

Referring Party Signature: DATE:

County of San Luis Obispo Government Center

P.O. Box 1149 | San Luis Obispo, CA 93406-1149 | (P) 805-781-5835 | (F) 805-781-1142 pa@co.slo.ca.us | http://sloacttc.com