IMPORTANT INFORMATION TO KNOW
for
(Your full name)
GENERAL
Date of Birth ____________________________________ SSN: ______________________________________________
Health Insurance: (indicate account numbers)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Current Medications: (include dosage, time and quantity i.e. 20mg, morning, daily)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Allergies: (drug or other)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
FINANCIAL INFORMATION
Bank Account (name of facility, location and account #) _____________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Saving Account (location and account #)_________________________________________________________________
__________________________________________________________________________________________________
Other Accounts (I.e. Ameritrade, CDs, IRAs, etc. by location and account #):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Safety Deposit Box (location and where to find keys) _______________________________________________________
__________________________________________________________________________________________________
Credit Cards (account #, date due):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ACH Deposits also known as Automatic Deposits (indicate date and if weekly, monthly or annually, and if posted to bank or credit card):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ACH Withdrawals also known as Automatic Withdrawals (indicate entity such as utility, insurance, etc. and if weekly, monthly or annually, and if posted to bank or credit card):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Other Payment Obligations/Debts: (indicate entity and amount if fixed)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Assets: (car, house, real estate, boats, etc. and any mortgage/loan information such as amount, payment, institution)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
LIFE INSURANCE AND OTHER LEGAL MATTERS
Power of Attorney and where to find ___________________________________________________________________
Living Will and where to find __________________________________________________________________________
Will and/or Trust and where to find ____________________________________________________________________
Executor and/or Attorney (include contact information) __________________________________________________________________________________________________
__________________________________________________________________________________________________
Signers/Agents on Accounts: (indicate who and what) __________________________________________________________________________________________________
__________________________________________________________________________________________________
Life Insurance: (indicate company, amounts, beneficiaries and insurance contact information)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
People or Agencies to Notify: (include contact information)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
FINAL WISHES
Burial, Cremation, or Other (include instructions such as green interment or ashes destination)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Memorial Service (include location such as church, funeral home, graveside, special hymns, verses, activity, OR none, etc.)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Memorial Marker Wishes __________________________________________________________________________________________________
__________________________________________________________________________________________________
Obituary Information
Parents’ names_____________________________________________________________________________________
Birth location and date ______________________________________________________________________________
Predeceased immediate family (parents, spouse, children, siblings including name and relationship)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Survivors (indicate name and relationship)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
MISCELLANEOUS (Heirlooms and belongings to dispense, eulogy information, etc.)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Signed: _____________________________________________ Date:_________________________________________
Print Name __________________________________________
Vicki L. Julian 2014. Permission granted for personal use only. All other rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, for commercial use or other distribution without written permission from and credit given to the holder of the copyright.
for
(Your full name)
GENERAL
Date of Birth ____________________________________ SSN: ______________________________________________
Health Insurance: (indicate account numbers)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Current Medications: (include dosage, time and quantity i.e. 20mg, morning, daily)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Allergies: (drug or other)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
FINANCIAL INFORMATION
Bank Account (name of facility, location and account #) _____________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Saving Account (location and account #)_________________________________________________________________
__________________________________________________________________________________________________
Other Accounts (I.e. Ameritrade, CDs, IRAs, etc. by location and account #):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Safety Deposit Box (location and where to find keys) _______________________________________________________
__________________________________________________________________________________________________
Credit Cards (account #, date due):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ACH Deposits also known as Automatic Deposits (indicate date and if weekly, monthly or annually, and if posted to bank or credit card):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ACH Withdrawals also known as Automatic Withdrawals (indicate entity such as utility, insurance, etc. and if weekly, monthly or annually, and if posted to bank or credit card):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Other Payment Obligations/Debts: (indicate entity and amount if fixed)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Assets: (car, house, real estate, boats, etc. and any mortgage/loan information such as amount, payment, institution)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
LIFE INSURANCE AND OTHER LEGAL MATTERS
Power of Attorney and where to find ___________________________________________________________________
Living Will and where to find __________________________________________________________________________
Will and/or Trust and where to find ____________________________________________________________________
Executor and/or Attorney (include contact information) __________________________________________________________________________________________________
__________________________________________________________________________________________________
Signers/Agents on Accounts: (indicate who and what) __________________________________________________________________________________________________
__________________________________________________________________________________________________
Life Insurance: (indicate company, amounts, beneficiaries and insurance contact information)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
People or Agencies to Notify: (include contact information)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
FINAL WISHES
Burial, Cremation, or Other (include instructions such as green interment or ashes destination)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Memorial Service (include location such as church, funeral home, graveside, special hymns, verses, activity, OR none, etc.)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Memorial Marker Wishes __________________________________________________________________________________________________
__________________________________________________________________________________________________
Obituary Information
Parents’ names_____________________________________________________________________________________
Birth location and date ______________________________________________________________________________
Predeceased immediate family (parents, spouse, children, siblings including name and relationship)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Survivors (indicate name and relationship)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
MISCELLANEOUS (Heirlooms and belongings to dispense, eulogy information, etc.)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Signed: _____________________________________________ Date:_________________________________________
Print Name __________________________________________
Vicki L. Julian 2014. Permission granted for personal use only. All other rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, for commercial use or other distribution without written permission from and credit given to the holder of the copyright.