County of San Diego Public Administrator
Request for Public Administrator Investigation
The Public Administrator has received your referral.
The Public Administrator Investigator will be contacting you by telephone in the near future to discuss the referral with you.
The Public Administrator Investigator will be contacting you by telephone in the next 3 business days. If you do not hear from them or have additional information that you would like to provide, please call 1-800-339-4661 during normal business hours and ask to speak with the Public Administrator Investigation Duty Worker or the Assistant Public Administrator
Referring Party Information
Fields with a red label are required:
Please complete as much information as you know:
If you do not hear from a Public Administrator Investigator within 3 business days, please contact 1-800-339-4661 and a Call Center Specialist will assist you.
Submit
Last Name:
First:
Relationship:
Phone:
Fax:
Email:
Address:
Apt #/Room #:
City:
State:
Zip:
Are you making this referral on behalf of an agency?
Yes
No
Agency Name:
Relationship:
Attorney/PF
APS
Bank/Credit Union
Court
Doctor
Family/Friend
Hospital
Law Enforcement
LPS
Medi Cal
Medical Examiner
Mortuary
Neighbor
Self Referral
SNF
Other
Is agency's contact information different from yours?
Yes
No
Phone:
Fax:
Email:
Address:
Apt #/Room #:
City:
State:
Zip:
Is there a person other than yourself who should be contacted regarding this referral?
Yes
No
Last Name:
First:
Relationship:
Phone:
Fax:
Email:
Address:
Apt #/Room #:
City:
State:
Zip:
Submit
Fields with a red label are required:
Please complete as much information as you know:
Decedent Information
Last Name:
First Name:
Middle Name:
Suffix:
Sr.
Jr.
I
II
III
IV
AKA's:
Date of Birth:
Place of Birth:
Gender:
Female
Male
Ethnicity:
American Indian
Asian
Black/African American
Hispanic
Not Reported/Unknown
Other Race
White/Caucasian
Admitted Date:
Date of Death:
Place of Death:
Cause of Death:
Mortuary/Cemetary:
Social Security Number:
Medi Cal #:
Referral Reason:
No Known NOK
Assets in Danger
NOK Resides Out of CA
Family Not Responsive
Other
Please Explain:
Marital Status:
Single
Married
Divorced
Widowed
Partnered
Spouse Last Name:
First Name:
Maiden Last Name:
Notified:
Yes
No
Unknown
Does Decedent have a Pre-Need?
Yes
No
Unknown
Has it been paid?
Yes
No
Unknown
Residence
Residence Facility:
Emergency Contact:
Address:
Apt #/Room #:
City:
State:
Zip:
Phone:
Relationships
Add Relationship
Did the deceased or his or her spouse serve in the military?
Serial #:
Branch:
Will:
Yes
No
Unknown
Executor
Last Name:
First:
Phone:
Fax:
Email:
Address:
Apt #/Room #:
City:
State:
Zip:
Notified:
Yes
No
Unknown
Landlord
Last Name:
First:
Phone:
Fax:
Email:
Address:
Apt #/Room #:
City:
State:
Zip:
Notified:
Yes
No
Unknown
Keys To Residence
Yes
No
Unknown
Location:
Financial Information
Does the decedent have a patient trust account?
Yes
No
If Yes, provide name:
Does the decedent have a representative payee?
Yes
No
If Yes, provide name:
Estate Assets (for example: bank accounts, real property information, location of wallets/keys, vehicles, patient trust accounts, representative payee account etc.)
Keys To Car:
Yes
No
Unknown
Location:
Notes