Barristers & Solicitors
2800, 801 6 Avenue SW
Calgary, Alberta T2P 4A3
Phone 403-267-8400
Fax 403-264-9400
Toll Free 1 800 304-3574
www.walshlaw.ca
DECEASED
Full Name of Deceased:
Any other name known by:
Occupation of Deceased at time of death (if retired, then former occupation and date of retirement):
Date of Birth:
Place of Birth:
Date of Death: Click here to enter a date.
Place of Death:
Date of Will:
Date of Codicil:
Location of Will (and Codicil):
Address of Deceased for 6 years preceding death:
Address:
Years resided at this address:
Was the Deceased’s habitual residence in the Province of Alberta?
If no, where did the Deceased reside?
Choose an item.
MARITAL STATUS
(Please check one) ☐ married
☐ common-law
Date of Marriage: Click here to enter a date.
☐ divorced
☐ widowed
Place of Marriage:
Surviving Spouse:
Address
Phone Numbers
Common-law Spouse:
Address
Phone Numbers
Former Spouse:
Date of Divorce/Date of Death
FAMILY INFORMATION
Surviving Children:
Birth Date
Name
Address (including postal code)
Are there any children physically or mentally handicapped?
If yes, please describe:
Choose an item.
Are any of the other beneficiaries physically or mentally handicapped?
If yes, please describe:
Have any of the Deceased’s children predeceased:
If yes, please describe:
Choose an item.
Choose an item.
Name of Deceased Child:
Date of Death:
Names and Addresses of their Children:
Birth Date
Did the Deceased have any children who were not children of the spouse, former spouse and/or common-law
spouse listed above?
Choose an item.
If yes, please provide details:
Was the Deceased responsible for any other children?
If yes, please provide details:
Choose an item.
Was the Deceased acting as an attorney under the Enduring Power of Attorney Act?
Choose an item.
If yes, please provide details:
ESTATE MATTERS
Did the Deceased leave a will?
If yes, please continue filling the information below.
Choose an item.
If no, please make a list of the names, addresses, occupations and phone numbers of each relative of the
Deceased. Please list the relatives in the following priority: spouse, children, grandchildren, parents, brothers
and sisters, etc. Also please provide the information requested below (as applicable).
WITNESSES
Will:
Name
Address
Occupation
Address
Occupation
Codicil:
Name
Are either of the Witnesses to the Will (or Codicil) a beneficiary
or spouse of a beneficiary under the Will?
Choose an item.
If yes, please explain:
PERSONAL REPRESENTATIVES
Note: Please complete this section if you are named as an Executor in the will or are applying for
administration where there is no will. Please add a page if additional space is required.
Name and Address
(Res)
Relationship to Deceased:
(Bus)
Occupation:
(Fax)
SIN:
(E-mail)
Date of Birth:
Name and Address
Relationship to Deceased:
(Res)
Occupation:
(Bus)
(Fax)
SIN:
(E-mail)
Date of Birth:
Are any Executors Renouncing?
Choose an item.
If yes, please specify:
BENEFICIARIES
Note: Please list the beneficiaries other than the Deceased=s spouse or children
Name and Address
Relationship
Birth Date
(if under 18 years)
ASSETS
Note: All amounts must be the value as at the date of death
Does the Deceased have a safety deposit box?
If yes, please specify the location:
Choose an item.
Please list the contents of safety deposit box: A complete list of assets is required including full names of companies, serial
numbers, maturity dates, number of shares, etc. All other contents can be listed generally (birth certificates, mementos, etc.).
In the margin please indicate the form
of ownership of each asset:
JT
TC
H
W
O
=
=
=
=
=
Joint Tenancy (i.e. with right of survivorship)
Tenancy in Common
Property owned by Husband
Property owned by Wife
Property owned with someone else other than spouse
REAL ESTATE
Market
Value
Principal Residence
$
Amount Owing on
Mortgages
$
$
$
$
$
(at date of death)
Municipal Address:
Legal Description:
_____ Names on Title:
Name of Mortgage Company
Are the mortgage(s) life insured?
Address
Choose an item.
Other Real Estate
Date of
Purchase
Legal Description
1
2
3
Acquisition
Cost
Mortgage
Amount
FMV
$
$
$
$
$
$
$
$
$
Registered Owners:
Registered Owners:
Registered Owners:
Mortgages and Encumbrances on Real Estate listed above:
Name and Address of Mortgage Company
Principal
Interest (from last
(indicate which property)
payment to date of death)
$
$
$
$
$
$
Mines and Minerals:
Legal Description:
Current Value: $
Is the property currently leased?
Choose an item.
Monies secured by Mortgage or by Agreement for Sale:
Name
Description of Land
Nature of Charge
Amount Owing
$
$
Cash: Cash on Person: $
BANK ACCOUNTS
Bank name and complete address
Account No./Type
Principal
$
$
$
Accrued
Interest
(to date of death)
$
$
$
GUARANTEED INVESTMENT CERTIFICATES / TERM DEPOSITS
Name and Address
Principal
Value
$
$
$
Purchase
Date
$
$
$
Maturity
Date
$
$
$
Interest
Rate
$
$
$
Paid
(Annual, semi-annually, monthly)
Any other items immediately convertible to cash (i.e. uncashed cheques, etc)?
DEBTS OWED TO DECEASED
Does anybody owe money to the Deceased (e.g. personal loans, promissory notes, mortgages, agreements
for sale, unpaid rent, sale of equipment or livestock, etc)?
Choose an item.
If yes, please describe:
LIFE INSURANCE POLICIES
Insurance Company
Policy No.
Face Value
$
$
Beneficiary
$
$
ANNUITIES
Name and Address
Principal
Amount
$
$
$
Monthly
Payment
$
$
$
Date of Last
Payment
Beneficiary
PENSION BENEFITS
Name and Address
Principal
Amount
$
$
Monthly
Payment
$
$
Date of Last
Payment
Beneficiary
REGISTERED RETIREMENT SAVINGS PLANS
Where held / Address
Amount
Beneficiary
$
$
$
Is any property being held in trust for the Deceased from another estate or trust? Choose an item.
If yes, describe:
SHARES IN PUBLIC CORPORATIONS, MUTUAL FUNDS, BONDS &
DEBENTURES
Name
Type
Class of Shares
& Number Held
Unit Value
$
$
$
Market Value
$
$
$
SHARES IN PRIVATE CORPORATIONS
Describe full name of company, shareholders, number and type of shares owned by each shareholder, nature
of business, assets owned by company, acquisition cost and current value:
Are there any restrictions on transfer?
Choose an item.
Is there a buy/sell or unanimous shareholders agreement?
Choose an item.
If yes, is it life insurance funded or otherwise funded?
Choose an item.
FARMING INTERESTS
Give description and value of machinery, cattle and other farm animals and produce, as at the date of death.
OTHER BUSINESS INTERESTS
Describe sole proprietorships, partnerships, joint ventures, etc.
PERSONAL EFFECTS
Description
Estimated Value
Household Goods
$
Jewellery
$
$
Automobile(s)
$
(year, make & serial no.)
Paintings, antiques,
collections or art collections
$
Other assets
Not listed above
$
LIABILITIES
Description of debts owed by Deceased (include funeral, charge cards, etc.)
Amount
$
$
$
$
Do you wish to advertise for creditors?
Choose an item.
ADDITIONAL INFORMATION REQUIRED
FOR ESTATE ADMINISTRATION
TAXATION MATTERS
Date of last Income Tax Return:
(please provide copy if available)
Who will prepare Terminal Tax Return?
Social Insurance Number of Deceased:
Was the Deceased, or the Deceased=s business registered to collect the Goods and Services Tax? Choose
an item.
If yes, what is the GST Registration Number? ___________________________
CANADA PENSION PLAN
Did the Deceased contribute to the Canada Pension Plan?
Date of Last Cheque: Click here to enter a date.
Choose an item.
Amount Received: $
Note: The Deceased is entitled to CPP and Old Age Security in the month of death. Cheques received after
that month must be returned.
Have you applied for:
Death Benefits:
Widow’s Benefits
Infant’s Benefits
Choose an item.
Choose an item.
Choose an item.
MISCELLANEOUS
Cause of Death:
Name of Attending Doctor during last illness:
(This information is only required if making a claim on insurance policies)
Was there a motor vehicle involved in any way in the death of the Deceased?
If yes, please complete the motor vehicle accident checklist
Choose an item.