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Note: Please type or print neatly in black or blue ink.

Beginning of first page:

In the matter of: Put the name of the deceased here.

Item 1: List your name and relationship to the deceased.

Item 2: Check the appropriate box and list the City/Township of deceased.

Item 3: List the total amount of the funeral and burial expenses. List the person(s) who paid the funeral home and the amount that was paid. List the amount of any unpaid funeral and burial expenses. Attach a copy of the funeral bill.


Item 4: List assets that were left in the decedents name only. The total value of the decedent's property remaining after payment of funeral and burial expenses cannot exceed $21,000.

All assets listed must have supporting documentation. Examples include a tax statement showing the value of real estate, a bank statement showing the amount of a bank account, a Kelley Blue Book printout showing the value of a vehicle.

Beginning of Second Page:

Item 5: List the name, age, relationship and address of the heirs of the decedent.

Item 6: Request the proper distribution of the assets of the deceased. Any person(s) who paid the funeral bill must be reimbursed first.

Date, sign and list your address and phone number.

Attach certified copy of Death Certificate and complete the Testimony of Interested Persons (PC565).

The Court completes the Order Assigning Assets.


The filing fee is $25 with an additional Estate Inventory Fee based on the value of the assets.

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