Organizing Your Personal Affairs
______ABOUT YOU______
Your legal name______
Address______
City______State______Zip Code______
Date of birth______Place of birth______
City______State______Zip Code______
Your citizenship______Your race______
Your religious affiliation______
Occupation or former occupation (kind of work you did most of your life)______
Your education: High School ______College______
Graduate School______Other______
______SIGNIFICANT OTHER______
Marital Status: ___Married ___Divorced ___Widowed ___Other______
Name of spouse______
Spouse’s place of birth______
______FAMILY______
Mother’s maiden name______Her place of birth______
Her address______
City______State______Zip Code______
Father’s name______His place of birth______
His address______
City______State______Zip Code______
______CHILDREN______
Name______Phone______
Name______Phone______
Name______Phone______
Name______Phone______
Name______Phone______
Name______Phone______
______GRAND CHILDREN______
Name______Phone______
Name______Phone______
Name______Phone______
Name______Phone______
Name______Phone______
Name______Phone______
Name______Phone______
Name______Phone______
Name______Phone______
______SIBLINGS______
Name______Phone______
Name______Phone______
Name______Phone______
Name______Phone______
Name______Phone______
Name______Phone______
______GOD PARENTS______
Name______Phone______
Name______Phone______
______OTHER PERTINENT FAMILY MEMBERS______
Name______Relationship______
Phone______
Name______Relationship______
Phone______
Name______Relationship______
Phone______
Name______Relationship______
Phone______
______MILITARY______
Dates of service______Branch of service______
Rank______Service Number______
Wars/conflicts served: First______Second______
Location of discharge papers (you will need a copy of these papers)______
______FRATERNAL ORGANIZATIONS______
Name______Address______
City______State______Zip Code______
Name______Address______
City______State______Zip Code______
______INSURANCE INFORMATION______
Health Insurance Company______Policy Number______
My policy is located at:______
Life Insurance Company______Policy Number______
My policy is located at:______
Beneficiary______Contingent______
My policy is located at:______
Long Term Care Company______Policy Number______
My policy is located at:______
Annuity Insurance Company______Policy Number______
My policy is located at:______
Disability Insurance Company______Policy Number______
My policy is located at:______
Other Policies: Company______Policy Number______
Amount______Reason Purchased______
My policy is located at:______
______PENSION DETAILS______
Name of Company______Phone______
Type (401k, RRSPs, RRIFs, etc.)______
Value______Other______
Name of Company______Phone______
Type (401k, RRSPs, RRIFs, etc.)______
Value______Other______
______CREDIT CARDS______
Card Type______Expiration Date______
Additional Card Holder______Relationship______
Telephone Number of Additional Card Holder______
Card Type______Expiration Date______
Additional Card Holder______Relationship______
Telephone Number of Additional Card Holder______
Card Type______Expiration Date______
Additional Card Holder______Relationship______
Telephone Number of Additional Card Holder______
Card Type______Expiration Date______
Additional Card Holder______Relationship______
Telephone Number of Additional Card Holder______
Card Type______Expiration Date______
Additional Card Holder______Relationship______
Telephone Number of Additional Card Holder______
Card Type______Expiration Date______
Additional Card Holder______Relationship______
Telephone Number of Additional Card Holder______
______SAFETY DEPOSIT BOX______
I have a Safety Deposit Box? ___Yes ___No Box Number______
It is located at______Contact Number______
Additional Key Holder______Contact Number______
In the event of no Additional Key Holder the contents of the box is to be opened by:
______Contact Number______
______FINANCIAL INSTITUTIONS______
Savings Account Location (Name of Bank)______
Name of Joint Account Holder______Phone______
Savings Account Location (Name of Bank)______
Name of Joint Account Holder______Phone______
Checking Account Location (Name of Bank)______
Name of Joint Account Holder______Phone______
Checking Account Location (Name of Bank)______
Name of Joint Account Holder______Phone______
______POWER OF ATTORNEY______
I have a will: ___Yes ___No
It is located at name/place:______Phone:______
City______State______Zip Code______
My attorney’s name is:______Phone:______
City______State______Zip Code______
The executor of my Will is:______Phone:______
City______State______Zip Code______
I have a living will: ___Yes ___No
It is located at:______
City______State______Zip Code______
I have a medical Power of Attorney: ___Yes ___No
It is located at:______
City______State______Zip Code______
The person designated under my Medical Power of Attorney is:______
Address______Phone:______
City______State______Zip Code______
______FUNERAL ARRANGEMENTS______
I have already made my funeral arrangements: ___Yes ___No
I wish to have my body: ____Buried (at______) ____Cremated (given
to______) ____Donated (to______)
I would like a: __Traditional Funeral __Direct Burial __Direct Cremation __Other(______)
I would like my ceremony to be: ___Religious ___Personalized ___Military ___Other______
I wish to have my funeral handled by:______
Phone______Address______
City______State______Zip Code______
I want my Viewing/Funeral to be: ___Open Casket ____Closed Casket ____Other______
I would like my service to be conducted by:______
Phone______
I would like my eulogy to be conducted by:______
Phone______
I would like to request the following people as Pallbearers:
Name______Phone______
Name______Phone______
Name______Phone______
Name______Phone______
Name______Phone______
Name______Phone______
I would like to be buried wearing______
I would prefer to be buried wearing my jewelry: ___Yes ___No
I would like to have the following songs played at my funeral:______
______
In honor of my memory I would prefer: ____Flowers be sent to the Funeral Home
___ Donations to be made to:______Other:______
Special Instructions:______
______ORGAN DONATION INFORMATION______
Are you an Organ Donor: ___Yes ___No
If it is at all possible I would like to have the following organs donated: _____None ____All
___Heart ___Liver ___Kidney ___Lung ___Pancreas ___Intestine ___Cornea
___Skin ___Bone ___Bone Marrow ___Eyes ____Other:______
Donor______Date______
Witness______Date______
Witness______Date______
______COPIES OF THIS DOCUMENT______
Copies of this document have been probated: ___Yes ___No
Copies of this document are kept by the following people:
Name______Phone______
Address______City______State______Zip______
Name______Phone______
Address______City______State______Zip______
Name______Phone______
Address______City______State______Zip______
Name______Phone______
Address______City______State______Zip______
Name______Phone______
Address______City______State______Zip______
HOW I WOULD LIKE MY HEADSTONE, FOOTSTONE,
& OBITUARY TO READ
The following should be followed:
___Exactly ___As a guideline ___At discretion ___Does not matter
Headstone:
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Footstone:
______
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Obituary:
______
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______SPECIFIC CONTACTS AT THE TIME OF PASSING VIA PHONE______
Call:(name)______At (phone)______
Tell them:______
______
______
Tell them to contact______At (phone)______
Call:(name)______At (phone)______
Tell them:______
______
______
Tell them to contact______At (phone)______
Call:(name)______At (phone)______
Tell them:______
______
______
Tell them to contact______At (phone)______
Call:(name)______At (phone)______
Tell them:______
______
______
Tell them to contact______At (phone)______
Call:(name)______At (phone)______
Tell them:______
______
______
Tell them to contact______At (phone)______
______SPECIFIC CONTACTS AT THE TIME OF PASSING VIA MAIL______
Name______Address______
City______State______Zip______
I already have a letter written for them: ___Yes ___No
If Yes it is located______
If No, Please write______
______
______
______
______
Name______Address______
City______State______Zip______
I already have a letter written for them: ___Yes ___No
If Yes it is located______
If No, Please write______
______
______
______
______
Name______Address______
City______State______Zip______
I already have a letter written for them: ___Yes ___No
If Yes it is located______
If No, Please write______
______
______
______
______
______CONFIDENTIAL______
THE FOLLOWING INFORMATION IS CONSIDERED PERSONAL & CONFIDENTIAL, THEREFORE IT IS TO ONLY BE VIEWED BY THE INTENDED RECIPIENT
This letter is intended solely for______
of (address)______(city)______(state)______(zip)______
______
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PUBLIC LETTER TO ALL IN ATTENDANCE AT MY FUNERAL FROM, ME
______
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I would like for the fore mentioned letter to be read aloud at my service by______,
or, if they are unavailable ______. Thank you in advance for complying with my wishes.
Sincerely,
______MY PERSONNAL INFORMATION______
Favorite Bible Verse______
Favorite Song______
Favorite Holiday______
Favorite Place______
Favorite Color______
Most Important Event in My Life______
Saddest Day of My Life______
Favorite Saying______
Lucky Number(s)______
Hobbies______
______
Most Prized Possession______
Best Friend(s)______
Accomplishments______
Favorite Charity______
Greatest Goal______
Favorite Movie______
Favorite TV Show______
Favorite Actor/ Actress______
Favorite Car______
Other Things of Personal Interest______
______
______
______
______
______AUTOMOBILE/ VEHICLE DETAILS______
Vehicle Model______Year______
Vehicle Identification Number______Tag______
Ownership Status: ___Own ___Leased ___Financed to Own
Leasing/ Finance Company______Phone______
Date of End of Lease/ Finance Period______Monthly Payment______
Co-owners Name______Phone______
Insurance Name______Policy Number______
Notes______
Vehicle Model______Year______
Vehicle Identification Number______Tag______
Ownership Status: ___Own ___Leased ___Financed to Own
Leasing/ Finance Company______Phone______
Date of End of Lease/ Finance Period______Monthly Payment______
Co-owners Name______Phone______
Insurance Name______Policy Number______
Notes______
Vehicle Model______Year______
Vehicle Identification Number______Tag______
Ownership Status: ___Own ___Leased ___Financed to Own
Leasing/ Finance Company______Phone______
Date of End of Lease/ Finance Period______Monthly Payment______
Co-owners Name______Phone______
Insurance Name______Policy Number______
Notes______
______IMPORTANT DOCUMENTS LOCATIONS______
Lock Box and/or Other Important Keys______
Birth Certificate(s)______
Children’s Birth Certificate(s)______
Marriage Certificate(s)______
Divorce Decree______
Adoption Papers______
Deeds and Titles______
Mortgages and Notes______
Income Tax Records/Returns______
Veteran Discharge Papers______
Other Important Papers (Please List)______
______
______PROFESSIONAL DIRECTORY______
Name______Profession______
Address______
City______State______Zip______
Phone______Fax______E-mail______
Notes______
Name______Profession______
Address______
City______State______Zip______
Phone______Fax______E-mail______
Notes______
______MEDICAL DIRECTORY______
Physician’s Name______
Address______
City______State______Zip______
Phone______Fax______E-mail______
Notes______
Specialist’s Name______
Address______
City______State______Zip______
Phone______Fax______E-mail______
Notes______
Chiropractor’s Name______
Address______
City______State______Zip______
Phone______Fax______E-mail______
Notes______
Dentist’s Name______
Address______
City______State______Zip______
Phone______Fax______E-mail______
Notes______
______PET DETAILS______
Name______Type______
This pet has papers: __Yes ___No The papers are located______
Pet to go to______
Address______
City______State______Zip______
Phone______Fax______E-mail______
Veterinarian’s Name______Phone______
Allergies______
Feeding Schedule______Vaccination Schedule______
Has the pet been spade, or neutered? ____Yes ____No
Name______Type______
This pet has papers: __Yes ___No The papers are located______
Pet to go to______
Address______
City______State______Zip______
Phone______Fax______E-mail______
Veterinarian’s Name______Phone______
Allergies______
Feeding Schedule______Vaccination Schedule______
Has the pet been spaded, or neutered? ____Yes ____No
Special Instructions______
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______MEDICAL HISTORY______
1). Parents and/or siblings had heart disease, kidney disease, diabetes, cancer, stroke, or any other hereditary disease? ( If yes, indicate family member, illness, age at onset, if applicable, age at death.)
___No ___Yes ______
2). Have you had problems with your circulatory, cerebrovascular or cardiovascular systems or blood vessels (such as: heart attack, heart disease, palipitations, heart murmur, chest pain, high blood pressure, stroke, anemia)?
___No ___Yes ______
3). Have you had problems your with nose, throat, lung or respiratory system (emphysema, asthma, shortness of breath, chronic cough or sleep apnea)?
___No ___Yes ______
4). Have you had problems with stomach, intestine, rectum, liver or pancreas (such as: hepatitis, ulcer, colitis, Crohn’s disease, or pancreatitis)?
___No ___Yes ______
5). Have you had problems with your nervous system (such as: epilepsy, seizures, multiple sclerosis, depression, suicide, eating disorder, dementia, Alzheimer’s, anxiety, mental illness)?
___No ___Yes ______
6). Have you had problems with your Endocrine system, bones, muscles, joints, eyes or skin (such as: diabetes, thyroid, lupus, arthritis, or back problems)?
___No ___Yes ______
7). Have you had Cancer, tumor(s), polyps, melanoma or any other malignancy?
___No ___Yes ______
8). Have you had problems with your sugar, albumin or blood in urine, or other illness or disease of the kidneys, bladder, or urinary system, prostate, breast, sexually transmitted disease, or any other reproductive disorder?
___No ___Yes______
9). Other than listed above are there any other pertinent health problems that your family should be aware of in your health history?
___No ___Yes ______
______NOTES______
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I hope this helps you with your clients and helps you make more sales.
Feel free to copy and use it freely. If you can add something better to it or make it better, then send me a copy of it back to me.
FREE AGENT RESOURCE WEBSITE
Mark Rosenthal
Field Marketing Director
Rosenthal Financial Services
R.F.S. means Real Fast Service
7179 Jonesboro Road Suite 202
Morrow, Georgia 30260 - Check out what I can offer you.
(770) 968-5757 office
1-877-968-5757 toll free
(770) 968-2657 fax