PERSONAL INFORMATION
Date of most recent information update:
Full Name:
Address:
Second Address (if applicable):_
Social Security Number: Home Phone Number: _ _______________Cell Phone Number: Email Address: Birth Date: ________________________ Place of Birth: Citizenship: Baptism Date:
Do you have a Will? □Yes □No If yes, date of last update: / / Do you have a trust agreement? □Yes □ No
Do you have a power of attorney? □ Yes □ No
Do you have an advance medical directive? □ Yes □ No Do you wish to be an Organ Donor? □Yes □NO If yes, the particulars are recorded at: ________________________________________________________________
Are you entitled to Military Benefits? □Yes □No
Dates of Service: _____________________________________________
Branch of Service:_____________________________________________
Serial Number: __________________________________________
Veteran’s Service Organization to contact: _______________________
Spouse’s Full Name: Living: □Yes □No If No, Date of Death Former Spouse: □Yes □No If Yes, Current Name
Address: Home Phone Number _____________________Cell Phone Number: ___ Email Address: ________ Birth Date/Place: _________ Citizenship:
Social Security Number: Does your Spouse have a Will? □Yes □No Last Will Executed on:
Deceased or Former Spouse’s Full Name: ________________________________________
Date and Place of:
Marriage: Death: Divorce:
Spouse’s:
Social Security number: Address: Home Phone Number: Cell Phone Number:
Father’s Full Name:
Living: □Yes □No
Home Phone Number: _ Cell Phone Number: Email Address: Date of Birth/Place:
Mother’s Full Name:
Living: □Yes □No
Home Phone Number: _ Cell Phone Number: Email Address: Date of Birth/Place:
Other Living Immediate Family Members:
FIRST to be notified
- Name: _______________________ ____________ Relation: ________________
Address: __________________________________________________________________
_
Home Phone Number: Cell Phone Number: Email Address: Date of Birth:
SECOND to be notified
- Name: ___________________________________ Relation: ________________ Address: __________________________________________________________
Home Phone Number:_______________________________________________________ Cell Phone Number: ______________________________________________ Email Address: _____________________________________________________________ Date of Birth: __________________________________________________________
BUSINESS, PROFESSIONAL AND ESTATE PLAN CONTACTS
My Employer is:
Company Name: Address:
Person to contact at Company: Phone Number: Email Address:
My Attorney is:
Name: Address:
Phone Number: Email Address:
My Financial Advisor/Broker is:
Name: Company Name: Address:
Phone Number: Email Address:
My Accountant/Tax Advisor is:
Name: Company Name: Address:
Phone Number: Email Address:
My Banker is:
Name: Company Name: Address:
Phone Number: Email Address:
My Executor is:
Name: Company Name: Address:
Phone Number: Email Address:
My Co-Executor is:
Name: Company Name: Address:
Phone Number: Email Address:
My Trustee is:
Name: Company Name: Address:
Phone Number: Email Address:
My Power of Attorney Agent is:
Name: Company Name: Address:
Phone Number: Email Address:
My Advance Medical Directive Agent as directed in my Living Will:
Name: Company ___ Name: Address: _____
Phone Number: Email Address:
My Insurance agents/companies are:
- Name: ___________________ Company: ________________________ Type of Insurance (health, life, disability, homeowners, car):
Address:
Phone Number: Email Address:
- Name: ________________________ Company: ________________________ Type of Insurance:
Address:
Phone Number: Email Address:
LOCATION OF IMPORTANT DOCUMENTS
The following documents may be necessary in establishing rights to insurance, pensions, Social Security, ownership, relationship, etc. Indicate location for each item listed.
Document | Location |
Will | |
General Durable Power of Attorney | |
Durable POA for Health Care / Advance Medical Directive | |
Trust Agreements | |
Adoption Papers | |
Military discharge papers | |
Social Security card | |
Medicare and Medicaid cards | |
Real Estate Title | |
Mortgage papers | |
Inventory of household goods | |
Marriage License | |
Divorce Decree/Property Settlement | |
Passport or Citizenship papers | |
Automobile Title (First Vehicle) | |
Automobile Title (Second Vehicle) | |
Bank books/Checkbooks | |
Bank Statements | |
Tax papers for current year | |
Tax returns for last 5 years | |
Birth Certificate | |
Survivor’s pension info | |
Insurance policies: | |
Life | |
Health | |
Disability | |
Automobile | |
Excess Liability | |
Long-term care | |
Long-term care facility contract | |
Stock Certificates/investments | |
Keys to cars and property | |
Address book/wallet/cell phone | |
Other |
Safe Deposit Box:
Box Location: Key Location: Inventory of Box Contents Location: Person with Access:
Name: Address:
Phone Number:
Passwords:
Organization/Device | I.D. | Password | Pin |
Online banking | |||
Debit card | |||
Debit card | |||
Credit card | |||
Credit card | |||
Credit card | |||
Computer | |||
Smartphone | |||
Email(s) | |||
PayPal | |||
Other electronic login/password | |||