Kern — Public Administrator Referral Form with Instructions (PDF)

Source: https://www.kernsheriff.org/documents/public-administrator/pa-referral-form-with-instructions.pdf

Public Administrator Referral Instructions

The referral form must be completed as much as possible to your best knowledge. If you are in possession of any important documents submit with the referral. Examples may be but not limited to:

• Will • Pre-Need • Death certificate • Financial documents • Copies of credit/debit cards • Additional next-of-kin information (if applicable)

Referrals can be submitted via fax, mail or email:

Fax No.: (661) 392-6758 Mailing Address: PO BOX 2226 Bakersfield, CA 93303 Email: KCSOPA@kernsheriff.org

Sincerely,

DONNY YOUNGBLOOD Kern County Sheriff-Coroner -Public Administrator

Public Administrator Mailing | PO Box 2226, Bakersfield, CA 93303 | Telephone (661) 392-6778 | Fax (661) 392-6758

County of Kern INTERNAL USE ONLY Public Administrator 34970 McMurtrey Ave, 2nd FL. DATE RECIEVED: ______________________________________ Post Office Box 2226 Bakersfield, CA 93303 DEPUTY NAME: ______________________________ 661-392-6778; FAX: 661-392-6758 www.kernsheriff.org

REFERRAL INFORMATION

DATE: REFERRING AGENCY: CONTACT NAME & ADDRESS: PHONE: E- MAIL: BASIS FOR REFERRAL Pre-Death Referral After Death Referral Medical/Critically Ill No NOK Hospital /admittance dates: _______________________________ NOK Unable/Unwilling Handle Facility No NOK Potential Loss/Misappropriation of Estate Assets Facility /admittance dates: ________________________ PERSONAL INFORMATION NAME:

LAST KNOWN ADDRESS:

DOB: PLACE OF BIRTH: SEX: Male Female SSN:

MARITAL STATUS: HUSBAND/WIFE:

DOD: PLACE OF DEATH: WILL / FINAL DISPOSTION WILL: NO YES Location: PRE-NEED: NO YES Location: BODY LOCATION: PERSONAL INCOME OCCUPATION/EMPLOYER: EMPLOYER ADDRESS: VETERAN STATUS: NO YES Branch of service:

THIRD PARTY PAYEE: NO YES Representative Payee:

SOCIAL SECURITY BENEFITS: NO YES Amount $ WELFARE BENEFITS: NO YES Amount $ NEXT OF KIN / HEIRS / POTENTIAL LEADS NAME: RELATIONSHIP: ADDRESS: PHONE / E-MAIL:

NAME: RELATIONSHIP: ADDRESS: PHONE / E-MAIL: ASSETS / REAL PROPERTY / PERSONAL PROPERTY REAL PROPERTY ADDRESS: SECURED: NO YES KEYS TO RESIDENCE: NO YES Location of keys: OWNED RENT Mortgage / Rent Payment $ Mortgage Company/Landlord: VEHICLE(S): NO YES Description: Location: FINANCIAL ACCOUNT: NO YES Account Number: Bank Name: SAFE DEPOSIT BOX: NO YES Location: CASH IN EFFECTS: NO YES Amount $: PERSONAL PROPERTY: NO YES Location: Comments: