Important Copyright & Legal Notice:

Personal Information Worksheet

Prepared by:

First, Middle, (Maiden), Last Name

(Signature)

Date Initially Completed:

(dd/mm/yy)

Revision Dates:

(dd/mm/yy)

Original Content by Adria Ellerbrock

This document does not constitute legal advice,nor is any information in it legally binding or
able to create a lawyer-client relationship. For legal services, please consult a lawyer or other professional resource.
Use of any information in this document constitutes acceptance of these terms and conditions.

www.amomentthatliveson.com | www.mygoodbye.us

TABLE OF CONTENTS

Introduction Page 3

Section 1: Personal Contacts Page 3

Section 2: Business Contacts Page 5

Section 3: Billing Contacts Page 7

Section 4: Credit Card Contacts Page 9

Section 5: Estate Documents Page 10

Section 6: Banking / Financial Information Page 11

Section 7: Important Documents Page 13

Section 8: Dispersion of Personal Property Page 15

Section 9: Computer Information / Passwords Page 16

Additional Resources (LegalZoom.com) Page 17

Conclusion Page 17

About the Author / Background Info. Page 18

Remember that this document is not legally-binding nor does it constitute legal advice. Please consult with a legal professional for execution of a Will or other documents that can be beneficial to those left behind after you die.

We recommend LegalZoom.com for your legal needs. Visit www.LegalZoom.com/moment for $10 off any order, compliments of A Moment That Lives On.

Introduction

One of the most difficult tasks after a loved one has died is locating all of their personal information so key contacts can be made and financial, investment, credit, etc. accounts can be handled accordingly. Imagine the task of searching your loved one’s residence looking for this information. It could be daunting!

The purpose of this document is pretty straight-forward. It removes the stress of ‘the search’ and provides all of your account/contact information in one place so accounts can be handled effectively and efficiently. This exercise benefits the person in charge of researching and organizing your information. I guarantee that they will be thankful you completed this document and saved them the extra heartache and headache from searching for this information.

This document is a FREE downloadable Microsoft Word file (can be downloaded at http://www.amomentthatliveson.com/MyGoodbye/freedocuments.htm). You can complete it on your schedule, save it on your computer or file it in your house or office, and also make revisions/updates in the future. This allows your planning to remain personal and private, and lets you be in charge of the information and where it is kept.

Please make it a goal to complete this document in its entirety, even if it’s not in one sitting. Even if the some of the sections below seem obvious or mundane to you, remember that the person reading this document is probably in a state of shock or grief, and might not have the mental or physical energy to try to piece everything together. If you don’t want to provide all of the information (e.g., account numbers), at least provide names / companies or where they could find additional information. In addition, if you own a business, please be sure to include that information.

The most critical part of this exercise is informing trusted friends and / or family members that this document exists and its location (please don’t put yourself in a position where your information could be compromised).

NAME(S) / CONTACT NUMBER or LOCATION / RELATIONSHIP
1. FAMILY MEMBERS / RELATIVES
If you don’t want to list all family members here, list primary members who can be responsible for notifying other people in your extended family about the details of your passing.
NAME(S) / CONTACT NUMBER or LOCATION / COMMENTS
2. GUARDIAN(S) (FOR MINORS)
3. CLOSEST FRIENDS
If you don’t want to list all your friends here, list primary friends who can be responsible for notifying other people in about the details of your passing.
You can also specify Facebook (or other online social Web sites) or the location of your address book (print or tangible) if you want this to be a resource for locating and notifying friends.
5. CHURCH OR OTHER RELIGIOUS ORGANIZATIONS
6. ALUMNI ASSOCIATIONS
7. CLUBS, SOCIAL GROUPS, CIVIC ORGANIZATIONS, ETC.
NAME(S) / CONTACT NUMBER / ACCOUNT NUMBER
1. PHYSICIAN(S)
2. HOSPICSE / HOME HEALTH
3. POWER OF ATTORNEY
4. EXECUTOR OF ESTATE
5. FINANCIAL ADVISOR(S)
6. ATTORNEY(S)
7. ACCOUNTANT
8. LIFE INSURANCE
9. PROPERTY INSURANCE
10. AUTO / BOAT INSURANCE
11. VETERANS INSURANCE
12. DISABILITY INSURANCE
NAME(S) / CONTACT NUMBER / ACCOUNT NUMBER
13. PET INSURANCE
14. OTHER INSURANCE
15. UNIONS
COMPANY OR PERSON’S NAME / CONTACT NUMBER / ACCOUNT NUMBER
1. MORTGAGE COMPANY
2. LANDLORD
3. AUTO / BOAT / RV / ETC.
LOAN / LEASE
3. AUTO LOAN / LEASE
4. HEALTH INSURANCE
5. PHYSICIANS
6. DENTAL INSURANCE
7. DENTIST
8. VISON INSURANCE
9. EYE DOCTOR
10. TELEPHONE COMPANY
11. CELL PHONE COMPANY
12. INTERNET COMPANY
COMPANY OR PERSON’S NAME / CONTACT NUMBER / ACCOUNT NUMBER
13. CABLE/TV COMPANY
14. ELECTRIC COMPANY
15. GAS COMPANY
16. WATER COMPANY
17. TRASH COMPANY
18.LAWN COMPANY
19. SUBSCRIPTIONS
20. MEMBERSHIPS
21. VETERINARIAN
22. OTHER
COMPANY NAME / CONTACT NUMBER / ACCOUNT NUMBER
1. VISA/MC/AMEX/DISCOVER ETC. – LIST ALL HERE
2. GAS CREDIT CARDS
3. DEPT. STORE CARDS
4. OTHER CREDIT CARDS
CONTACT INFORMATION / WHERE PAPERS ARE LOCATED
1. TRUST
2. LAST WILL & TESTAMENT
3. LIVING WILL
4. DURABLE POWER OF ATTORNEY
5. CEMETERY PLOT DEED
6. PRE-PAID FUNERAL PAPERS
7. OBITUARY INFORMATION
8. MY GOODBYE PLANNING DOCS
9. INSURANCE BENEFICIARY PAPERS
5. PRE-PAID SERVICE PAPERS
BANK / INSTITUTION NAME / ACCOUNT NUMBER / WHERE STATEMENTS ARE LOCATED
1. CHECKING ACCOUNT(S)
2. SAVINGS ACCOUNTS
3. SAFE / LOCK BOXES
4. RETIREMENT ACCOUNTS/ PENSIONS
5. INVESTMENT ACCOUNTS (INCLUDE STOCKS, BONDS,
CDs, MUTUAL FUNDS, ANNUITIES, ETC.)
5. COLLEGE SAVINGS PLANS
LOCATION / NOTES / COMMENTS
1. SOCIAL SECURITY CARD / (Put social security number here)
2. BIRTH CERTIFICATE
3. PASSPORT/CITIZENSHIP DOC.
4. ADOPTION PAPERS
5. DRIVER’S LICENSE #
6. MARRIAGE LICENSE
7. PRE-NUPTIAL AGREEMENT
8. DIVORCE PAPERS
9. CUSTODY PAPERS
10. MILITARY PAPERS
11. REAL ESTATE DEEDS
12. MOTOR VEHICLE TITLE(S)
13. OTHER OWNERSHIP TITLES
14. APPRAISALS
15. TAX RETURNS (FED & STATE)
16. PROPERTY TAXES
17. BUSINESS DOCUMENTS
Include corporation, ownership papers, financing papers, payroll records, employee records, employee benefits, and other partnership or business agreements.
ITEM / PERSON OR ORGANIZATION WHO SHOULD RECEIVE THE ITEM
1. PERSONAL PROPERTY
List any owned property that you want to go to a specific person / organization (and not charity) here. For example, cars, clothing, jewelry, antiques, heirlooms, artwork, etc.
Note that this document is NOT legally binding, so in order for this information to be legally considered, it must be provided in a will. Please contact a lawyer or other reputable professional in the creation of a will and other legal documents.
PET’S NAME / TYPE OF ANIMAL / PERSON OR ORGANIZATION WHO SHOULD TAKE CARE OF THIS PET
If you have pets and know who you would like to take care of them after you die, fill out this section.
WEB SITE / PASSWORD(S)
1. EMAIL ADDRESSES
2. ONLINE ACCESS
If you can list out password protected Web sites and their related usernames and passwords, please do so.
If you only want to provide a list of commonly-used passwords, which will also be a big help to anyone trying to access your online accounts after you die.
INFORMATION
1. OTHER

Additional Resources

In addition to filling out important personal documents like this Personal Information Worksheet and the others made available to you at http://www.amomentthatliveson.com/MyGoodbye/freedocumentsform.htm, it’s also critical that you complete legal documents. Legal documents help you protect and provide for your family after your passing.

We endorse www.LegalZoom.com as an additional resource for legal death preparation documents such as a Last Will and Testament, Living Trust, Living Will, Power of Attorney, Pet Protection Agreement, and more. LegalZoom.com is the nation’s leading online legal document service. Their founding vision was for an easy-to-use, online service that would help people create their own legal documents. They brought together some of the best minds in the legal and technological fields to make this vision a reality.

At www.AMomentThatLivesOn.com, we support their vision and trust that you will get the legal services you need to complete each step of the death planning process. Visit www.LegalZoom.com to access and complete your online legal documents today.

Conclusion

Thank you for taking the time to read and fill out this document. Hopefully it was an exercise that gave you some peace of mind despite its purpose. Someday, your family and friends will be glad that they have this information to reference.

Please be sure to file this document with your other legal / death planning documents.

# # #

We all know the saying, “The only certain thing in life is death and taxes.” It’s unfortunate that Americans spend countless hours every year on tax returns but won’t spend one second preparing for the ultimate, inevitable life event — death.

Society seems to follow an “unspoken rule” regarding the preparation for death. Unless someone is old or terminally ill, the norm is for us to live our lives and let someone else deal with the details when our last breath is exhaled.

In addition, our culture teaches us death is not acceptable to think about, discuss, or — heaven forbid — plan for. Since it's not going to be our problem once we're gone, why worry about it while we’re alive?

The reality is that death is hard enough on those who are left behind without the additional stress of choosing a casket, determining a funeral program, or deciding what to feed people at the reception.

After losing a loved one, logic and emotion shouldn’t be forced to hold hands; yet standard practices command family and friends to do just that. The stress and confusion over how to handle important decisions while preparing a funeral to honor the deceased’s life is a nightmare... But someone dies in America every twelve seconds.

And that’s a lot of heartache.

The unanswered question is "Why?" Why do we allow ourselves to be in such fragile positions? Why don’t we care more about what happens to those who are left behind after we die?

Maybe we’re selfish. Maybe death is too overwhelming to plan for or prepare for on paper. Maybe we think it’s a crazy exercise to do while we're young(er). But we must remember, we all won’t live to the average age, and we all won’t die in our sleep at age 90.

The bottom line is that it's time to change the way things are done... not for ourselves, but for those people we love.

I created www.AMomentThatLivesOn.com and this planning document and hope that they are a reflection of how passionate I am about my vision to spare extra headache and heartache when someone loses a loved one. I trust that the information provided is both comprehensive and beneficial and serves its purpose in many, many lives across many, many miles.

Adria A. Ellerbrock, MBA

www.AMomentThatLivesOn.com