Vicki L. Julian
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IMPORTANT INFORMATION TO KNOW

for

 

(Your full name)

GENERAL

Date of Birth ____________________________________  SSN: ______________________________________________

Health Insurance: (indicate account numbers)

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Current Medications: (include dosage, time and quantity i.e. 20mg, morning, daily)

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Allergies: (drug or other)

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FINANCIAL INFORMATION

Bank Account (name of facility, location and account #) _____________________________________________________

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Saving Account (location and account #)_________________________________________________________________

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Other Accounts (I.e. Ameritrade, CDs, IRAs, etc. by location and account #):

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Safety Deposit Box (location and where to find keys) _______________________________________________________

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Credit Cards (account #, date due):

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ACH Deposits also known as Automatic Deposits (indicate date and if weekly, monthly or annually, and if posted to bank or credit card):

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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):

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Other Payment Obligations/Debts: (indicate entity and amount if fixed)

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Assets: (car, house, real estate, boats, etc. and any mortgage/loan information such as amount, payment, institution)

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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) __________________________________________________________________________________________________

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Signers/Agents on Accounts: (indicate who and what) __________________________________________________________________________________________________

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Life Insurance: (indicate company, amounts, beneficiaries and insurance contact information)

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People or Agencies to Notify: (include contact information)

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FINAL WISHES

Burial, Cremation, or Other (include instructions such as green interment or ashes destination)

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Memorial Service (include location such as church, funeral home, graveside, special hymns, verses, activity, OR none, etc.)

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Memorial Marker Wishes __________________________________________________________________________________________________

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Obituary Information

Parents’ names_____________________________________________________________________________________

Birth location and date ______________________________________________________________________________

Predeceased immediate family (parents, spouse, children, siblings including name and relationship)

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Survivors (indicate name and relationship)

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MISCELLANEOUS (Heirlooms and belongings to dispense, eulogy information, etc.)

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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.



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