SAMPLE. Important Information for My Family

Transcription

1 Important Information for My Family This guide is intended to provide your family with one centralized location for all vital information and records needed upon your death or disability.

2 Your Full Name Your Personal Information Date Completed Home Address Home Telephone Number Cell Date of Birth Social Security Card Location Place of Birth Birth Certificate Location Name of Person Who Will Handle Your Affairs Father s Name Date of Father s Death Place of Burial Mother s Maiden Name Date of Mother s Death Place of Burial Spouse s Full Name Date of Birth Father s Name Date of Your Marriage Your Parents Information Father s Place of Birth Cause of Father s Death Mother s Place of Birth Cause of Mother s Death Your Spouse s Information Mother s Maiden Name Place of Your Marriage Marriage Certificate Location

3 First Child s Full Name Your Children s Information Second Child s Full Name Third Child s Full Name Fourth Child s Full Name Primary Care Physician s Name Describe any other information you would like to include in your health information: Your Health Information Your Blood Type Spouse s Blood Type Are you an organ donor? If yes, location of authorization (i.e. online state registry or state motor vehicle office) Do you have a Living Will or Advance Health Care Directive? If yes, location of document(s) Your Pet s Information Pet s Name(s) Type Breed Sex Neutered/Spayed? Birth Date Location of Records Special Needs? Name of Veterinarian Who should care for your pet(s)?

4 Your Medications Drug Name Prescribing Doctor Prescription Number Dosage Pharmacy Your Spouse s Medications Drug Name Prescribing Doctor Prescription Number Dosage Pharmacy Your Children s Medications Drug Name Prescribing Doctor Prescription Number Dosage Pharmacy

5 Asset and Liability Information Assets/Liabilities Description Identification/Policy # Loan/Lien? Beneficiary Document Location Real Estate Real Estate Automobile Automobile Other Stocks Mutual Funds Bonds Savings Account Checking Account Other Account IRA IRA Auto Insurance Life Insurance Life Insurance Long Term Care Ins. Credit Card Ins. Disability Insurance Accident Insurance Other

6 Advisor Information Advisor Name Address Phone/ Insurance Agent Financial Advisor Lawyer Accountant Banker Stockbroker Primary Doctor Trust Account Clergy Funeral Home Estate Administrator Other Are your services pre-planned? Are your services pre-paid? If yes, contact Funeral Arrangements Do you have a plot purchased? If yes, plot location Preferred disposition of body (check one): Buried in cemetery Placed in crypt in mausoleum Cremated and ashes buried, scattered, or placed in urn Donated to medical school t embalmed except as specifically required by law Other Do you want a funeral service? If yes, location preference What type of service (check one)? Full funeral service with viewing Full funeral service with no viewing Graveside service (no viewing) Memorial service after burial Viewing with no service Other I would like to have (check one): A public viewing A private viewing (family or invitation only) A fully open casket A partially open casket viewing, special instructions List any personal items you wished to be buried with If cremated, where should ashes be scattered or kept? List any eligible military honors or benefits Headstone, grave site marker, and/or epitaph wording

7 Memorial Service Wishes Your place of worship Clergy s name to conduct service Favorite flowers In lieu of flowers, donations can be sent to (list memorial funds or charitable organizations) List favorite song or type of music to be played List any favorite readings, psalms, or verses List any favorite quotes or poems List any special requests or prayers Obituary Information Do you wish to have an obituary published? If yes, what would you like to include? Answering the following questions will help get you started. Where did you grow up and go to school? Who are (were) your parents and siblings, where were they born? Did you get married and/or have children? List their name(s) List any grandchildren and great-grandchildren List organizations you have volunteered/supported/or belonged to List any degrees, honors, military service, or accomplishments Describe anything else you would like to include in your obituary Document/Item Address Book Monthly Utility, Credit Card Statements, Other Bills Certificates/Papers for: Birth, Marriage, Adoption, Legal Guardianship, Divorce etc. Insurance Records Income Tax Records Passport/Naturalization Records Social Security Card Employment Information/Papers Medical Records Will, Living Will, or Trust Documents Military Service Records Safe or Safety Deposit Box including key(s) Keys for Home, Vehicles, etc. Deeds or Leases Passwords (online accounts, computer, phone etc.) Important Document and Personal Items Location Location

8 People Helping People In Time of Need Form 4617 P.O. Box 1527 Madison, WI (608) Fax (608)