SALEM COUNTY SURROGATE’S COURT INFORMATION SHEET NICKI A. BURKE – SURROGATE 92 Market Street, Salem, NJ 08079 Tel. (856) 935-7510 Ext. 8323 FAX: (856) 339-9359 Website: www.salemcountynj.gov E-Mail: surrogate@salemcountynj.gov Will / Administration- (Asset Sheet Required R.4:80-1b) / Administration Ad Prosequendum / Affidavit in Lieu of Administration Guardianship / Other DOCKET NO. _________________ TODAY’S DATE: ________________ INFO REC’D: ESTATE OF: IN PERSON [ ] PHONE [ ] ATTY [ ] _______________________________________________AKA________________________ LEGAL DOMICILE AT TIME OF DEATH:_______________________________________________________ DATE OF DEATH _______________ DATE OF BIRTH ______________ DATE OF WILL ____________ SS# _____________________ PAGES IN WILL ________________ (please enclose a copy of will) Name(s) & Address(es) of Executor(s), Administrator(s) : Name Address Marital Status: Married[ ] Widowed[ Certified Domestic Partnership [ ] Children of decedent: Son(s)[ ] Children from previous marriage[ ] Relationship Never Married[ ] Civil Union [ ] Phone Divorced[ Daughter(s)[ ] None[ ] ] Children of Deceased Children[ ] ] Stepchildren[ ] Next of Kin: Begin with spouse and children (guardian of minor children). If none, include parents and/or siblings. Indicate if they will be renouncing (use reverse side or additional sheet if necessary.) Age if Indicate if Name Relationship Address Minor Renouncing __________________________________________________________________________________ ( ) __________________________________________________________________________________ ( ) __________________________________________________________________________________ ( ) __________________________________________________________________________________ ( ) __________________________________________________________________________________ ( ) Self Proving Will: Yes [ ] No [ ] If NO, Name(s) and Address(es) of Witness(es) who will prove: ________________________________________________________________________________ # of Certificates Needed _______Payment: Cash [ ] Check [ ] Atty Escrow [ ] Mail to Atty [ ] Give to Executor/rix [ ] Name, Address & Phone # of Attorney_______________________________________________________ ______________________________________________________________________________________ OFFICE USE: DOD____ DOW____DOI____QUARTERLY____SS____BK&PG____DOCKET____SCAN____ American LegalNet, Inc. www.FormsWorkflow.com