Another Personal Record for Your use

I apologize for the poor quality of this document. However, it does contain a lot of useful information. PERSONAL RECORDS FOR ________________________ Use this workbook to keep track of your personal records and information for your loved ones. Knowing this information will be helpful to your executor, agent and family if you die or become incapacitated. Keep these records in a safe place. Make sure an appropriate person knows where to look for them. Be sure to update these records from time to time. 1. Information Regarding These Records This information was entered in this workbook on the _____ day of ________________, 20__, by_________________________________________________. The original of these records is kept: (Give Location) ____________________________ _______________________________________________________________________. (If applicable) A copy of these records is kept: (Give Location) ___________________ _______________________________________________________________________. 2. Personal Information My legal residence is: City State County Date of Birth: Month Day Year Place of Birth: City County State Birth Records are located at: If citizen of Date entered Foreign country U.S.A.: Citizenship Papers at: I Currently Am Married to: First Middle Maiden Name Wedding: At Mo. Day Year City County State Birth Date of Spouse: Month Day Year Place of Birth: City County State Country My Children are: (List Name, Birthdate and Current Address) If no children, list brothers and sisters. Former Marriages (list all): Former Spouse: First Middle Maiden Name If marriage ended in death: Date Month Day Year Cause of Death: Cause City Age If marriage ended in divorce: Date Month Day Year Place of Divorce: City State Records at: Attorney: Former Spouse: First Middle Maiden Name If marriage ended in death: Date Month Day Year Cause of Death: Cause City Age If marriage ended in divorce: Date Month Day Year Place of Divorce: City State Records at: Attorney: Former Spouse: First Middle Maiden Name If marriage ended in death: Date Month Day Year Cause of Death: Cause City Age If marriage ended in divorce: Date Month Day Year Place of Divorce: City State Records at: Attorney: Former Spouse: First Middle Maiden Name If marriage ended in death: Date Month Day Year Cause of Death: Cause City Age If marriage ended in divorce: Date Month Day Year Place of Divorce: City State Records at: Attorney: Parents: Father: Date Place Born: Died: Buried at: Mother: (Maiden Name) Date Place Born: Died: Buried at: Military Service: No military service Branch of Service: Country From: To: Date of Type of Discharge: Discharge: Highest Grade Or Rank Attained: Employment: My present employer is: Name Address Phone Date Started: Supervisor: Social Security No.: Card located at: In addition, I am eligible under the following pension, profit sharing and other benefit plans: 1. 2. 3. 4. I am am not a member of a Labor Union. Name of Local: Address Phone I am am not a member of a Credit Union. Name Address 3. My Estate Planning Documents My Will: I have no Will. Original executed copy of my will is located at It is dated , The original executed Codicil (revision), if any, is located at: It is dated , Attorney who drew my will is: Name Address Phone Names of Executor(s) and Trustee(s): Names of Guardians of my Children: Witnesses to Will: (List Names and Addresses) My Directive to Physicians and Family or Surrogates (“Living Will”): I have a “Living Will” I have no “Living Will” It is located at and is dated My Medical Power of Attorney: I have a Durable Power of Attorney for Property ____ I have no such power _____ It is located at and is dated My Durable Power of Attorney for Property: I have a Durable Power of Attorney for Property ____ I have no such power _____ It is located at and is dated The attorney who drew this document is My Declaration of Guardian: I have a declaration of whom I want to be my guardian should the need later arise _____ I have no declaration of guardian _____ It is located at and is dated My Trusts: I have created (or am a beneficiary of) the following trusts: Trust Name: Date of Trust Instrument: Original Trust Instrument is Located At: Name and Address of Current Trustee: Name and Address of Successor Trustee(s): Trust Name: Date of Trust Instrument: Original Trust Instrument is Located At: Name and Address of Current Trustee: Name and Address of Successor Trustee(s): Trust Name: Date of Trust Instrument: Original Trust Instrument is Located At: Name and Address of Current Trustee: Name and Address of Successor Trustee(s): Other Estate Planning Documents: (Please describe and state location) Insurance Life Insurance: I do do not have Life Insurance. Complete itemized list can be found. Policies are located at: Policies Covering Others: I own insurance policies on the lives of others. A list of companies and policy numbers is located at: Name of persons insured: I have have not made loans against some of the policies. Source of Loan: Address Phone Pertinent papers are filed with the policies: (Check) ___ Endorsements ___ Dividend Payments ___ Premium Receipts ___ Assignments ___ Settlement Agreements Annuities: I do do not have annuities: Detailed list is located at: Location of annuity contracts: My principal life insurance broker is: Name Address Phone Medical and Long Term Care Insurance: Accident, Hospitalization, Disability, Long term care and all other insurance (in addition to and exclusive of those covered by employer) not noted elsewhere. Location of List: Location of Policies: Broker/agent Phone Medicare: I am am not registered for Medicare. Enrollment at Date City State Medicare card located at: 5. My Assets and Liabilities Safe Deposit Boxes: I have have not a safe deposit box(es.) Located at Keys will be found at No. No. The following person has access: (Name and Address) No. No. Accounts: Checking Accounts: With Number With Number Savings Accounts: With Number With Number Other Accounts: With Number With Number With Number With Number Passbooks located at: Accounts in joint names with myself and: (Name & Acct. No.) Name of person who power to sign checks for me: Address Phone Real Estate: I do do not own real estate. I am the sole owner. It is located at: Mortgage on my residence is held by: The following documents are located at: Check (X): ___ Deed ____ Mortgage Insurance Policy ____ Copy of Mortgage ____ Title Abstract ____ Improvement Loans ____ Closing Statement ____ Title Insurance ____ Leases ____ Tax Receipts ____ Maps & Surveys Other Real Estate I own: _____ I am sole owner. Documents pertaining thereto are located at: Insurance Coverage is handled by: Name of Broker Address Phone Policies are located at: I lease property to others: Yes No Vacant Improved To: Name Address Phone At List Location Leases can be found at: U. S. Savings Bonds: I do do not own U.S. Savings Bonds. ____ I am sole owner. List of Bonds – Serial Numbers – Co-ownership – and who is a Beneficiary at my death can be found at: Bonds are located at: Securities (Stocks and Bonds): I do do not own securities (Stocks & Bonds). List of all securities and certificate numbers will be found at: Certificates located at: I do do not have a brokerage account. Name of Broker or Firm: Name Address Phone Records of Purchase and Sale are located at: List Securities pledged for loans: with Lender Address with Lender Address with Lender Address Personal Property: I own the following personal property: Auto: Yes No 1. Make Year 2. Make Year Title(s) located at: Household Furnishings: Yes No Located at: Record of Inventory located at: Jewelry: Yes No Inventory List & Appraisals at: Boat: Yes No Make Year Motor Year Located at: Miscellaneous Personal Property – (not previously listed): Pertinent insurance policies on personal property are located at: Insurance Broker: Name Phone Proof of Ownership, Receipts, Bills of Sales, etc., are located at: Miscellaneous Assets: List here other assets you own that are not otherwise covered above. Credit Cards: I possess the following credit cards: Other Liabilities: Mortgages, notes, and other debts not noted elsewhere. Description: Description: Description: Description: Description: Description: Tax Records: Copies of previous years tax returns filed are located at: Party who prepared or assisted in tax returns: Work sheets and evidence in support of returns are located at: Current withholding tax forms and receipts received from my employer are located at: 6. Burial (Please note: A special form is required to leave binding burial instructions. You can indicate your wishes here, but those indications are not binding on your family. Ask a lawyer at Barnes & Karisch, P. C. for more information. I do do not own a cemetery lot. Cemetery Lot: Name of Cemetery Describe location Deed located at: There is is not provision for perpetual care. I have given instructions regarding my funeral in: Letter Other: List membership in lodges or fraternal organizations providing cemetery benefits: My preference for burial would be at: Name of Cemetery City Religious Affiliation: List Church or Temple Address Pastor or Rabbi Phone 7. Persons Familiar With My Affairs Please print name, address and phone number. Attorney: Accountant – Tax Counselors: Banker: Doctor: Employer: Funeral Director: Insurance Agent: Executor of Estate: Fraternal or Professional Groups: (Please notify) Relatives and Personal Friends: (Please notify)