A Comprehensive Handbook of Personal Information. for. Prepared by:

Transcription

1 A Comprehensive Handbook of Personal Information for Prepared by: South Bend Indianapolis

2 General Instructions This handbook can be completed by individuals desiring to organize their information in case of emergency. Complete all applicable pages and either provide it to a loved one/trusted advisor or store it in a secure location with instructions to several people as to its whereabouts. Your family and loved ones will appreciate your efforts in completing it. Should you have any questions or need assistance, please do not hesitate to contact a Senior 1 Care representative at South Bend (574) Indianapolis (317) This Document is proprietary information of Senior 1 Care and is not to be copied, reproduced, or duplicated without the express written consent of Senior 1 Care.

3 Table of Contents Topic Page # General Information 1 Professional Advisors 4 Medical Professionals 5 Past Medical History 6 Listing of Medications Taken 7 Comments about Care Needs 8 Emergency Contacts 9 Legal Power of Attorney/Living Will 10 Listing and Location of Key General Information 11 Listing and Location of Financial/Legal Documents 12 Listing and Location of Financial Accounts/Assets 13 Financial Statements Current Personal Balance Sheet 15 Current Sources of Income and Expenses 16 Personal Desires 18 Instructions upon Death 19

4 General Information for Topic Name Address Telephone Address Birth Date Location of Birth Parents Response Street City Zip Home Cell Work Other Mother s Maiden Name Educational Institution(s) Name of Institution Degree Date Name of Institution Degree Date Marriage(s) 1. Married to Spouse Maiden Name _ Date Location Deceased Date/County 2. Married to Spouse Maiden Name _ Date Location Deceased Date/County 1

5 General Information Cont. Children Name Address/Phone Social Security # Spouse s Name Grandchildren/ Parents Name Address Social Security # 2

6 General Information Cont. Grandchildren/ Parents Cont. Date(s) of Death: Children Grandchildren 3

7 Professional Advisors for Type Legal Accountant Banker Investment Advisor Trustee/Trust Institution Insurance Agent Executor Other Name/Address/Phone/Contact Person 4

8 Medical Professionals for Type of Professional Primary Physician Dermatologist Cardiologist Gastroenterologist Urologist OB/GYN Orthopaedist Neurologist Podiatrist Dentist Ophthalmologist/ Optometrist Name/Address/Phone/Contact Person 5

9 Past Medical History for Procedure Approximate Date 6

10 Medications Taken by Medicine Dosage Frequency Comments 7

11 Comments about Care Needs for Comment below about special care needs. This could include allergies, special foods, food restrictions, cooking instructions, required exercise, physical limitations, etc. 8

12 Emergency Contacts for List below in order of contact the individuals to be contacted in case of emergency. Name Address/Telephone/Relationship 9

13 Legal Documents for Within this section include copies of the following documents and who has received copies. Document Financial Power of Attorney Health Care Representative Power of Attorney Living Will Copies Provided to 10

14 Location of General Information for Document/Information Birth Certificate Social Security Card Passport Drivers License Marriage Certificate Prenuptial Agreement Divorce Papers Adoption Papers Safe Deposit Box/Keys Spouse Death Certificate Military Discharge Papers Original Last Will and Testament Financial POA Health Care Representative Living Will Funeral Information/Preferences Obituary Information Location 11

15 Location of Financial/Legal Documents for Financial/Legal Documents Checkbook Past Three Years Paid Bills Three Years Prior Year Tax Returns Vehicle Titles Mortgage Documents Real Estate Deeds/Title Papers Trust Documents Life Insurance Policies Long Term Care Insurance Policies Property and Casualty Insurance Medical Insurance Disability Insurance Vehicle Insurance Promissory Notes Loans Outstanding Rental Agreements Appraisals/Inventory of Valuables (Describe) Lawsuit Information Partnership/L.L.C. Agreements Location 12

16 Location of Financial Accounts/Assets for Investments/Retirement/ Institution Name Statement/Document Bank Accounts Account # Location Checking Accounts Money Market/Savings Accounts Certificates of Deposit Credit Cards Brokerage/Mutual Funds Stock Certificates/Bearer Bonds Investment Club Records 13

17 Location of Financial Accounts/Assets Cont. Investments/Retirement/ Institution Name Statement/Document Bank Accounts Account # Location IRAs/401(k)s (including beneficiary forms) Deferred Compensation Agreements 529 College Savings Accounts Pension/Retirement Accounts (including beneficiary forms) Real Estate Owned Cost Basis of Investments Owned Listing of Other Investments/ Assets Other 14

18 Personal Balance Sheet for As of Date Assets (What You Own) Cash on Hand $ Checking Account Other Bank Accounts Certificates of Deposit Investment Accounts Brokerage Mutual Funds Stock Investments Accounts/Loans Due From Others Pension Payments Due 401(k)/IRA Accounts Real Estate Owned Vehicles Owned Personal Property Other Assets (List) Total Assets $ Liabilities (What You Owe) $ Mortgage Loan Balance Home Equity Loan Car Loan Balance Credit Card Balance Other Borrowings Taxes Payable Total Liabilities Net Worth (What You are Worth) Total Liabilities and Net Worth $ Prepared by Date 15

19 Sources of Current Income for As of Date Source of Income Approximate Monthly Dollar Amount Social Security Pension Payments Retirement Account Distributions Interest Dividends Veterans Benefits Other 16

20 Current Monthly Expenses for As of Date Re-occurring bills are paid monthly for the following: Company Paid to Amount Comments 17

21 Personal Desires of If I unexpectedly become physically or mentally incapacitated, I have listed below issues I desire my family, advisors and caregivers to consider. These items are in addition to what is contained in my last will and testament. (Include such items as desired living location(s), desired caregivers, driving restrictions, preferred advisors for your family, etc.) 18

22 Instructions upon Death of At the time of my death I would like my loved ones to the consider the following: Funeral Home Cemetery Telephone Contact Person Telephone Contact Person 19