**Career Transition Center**

**George P. Shultz National Foreign Affairs Training Center**

**U.S. Department of State**

**ME**

**IN A NUTSHELL**

![](media/image1.wmf){width="2.1902777777777778in"
height="3.957638888888889in"}

**[TABLE OF CONTENTS]{.underline}**

**[QUICK GUIDE TO LOCATIONS]{.underline}**
...............................................................3

# PERSONAL & FAMILY

MY PERSONAL
INFORMATION.....................................................................\...4

MY MARITAL
HISTORY...................................................................................6

MY SPOUSE
................................................................................................8

MY FAMILY HISTORY
..................................................................................13

MY MEDICAL INFORMATION
........................................................................16

EMERGENCY NOTIFICATION
.......................................................................19

# BUSINESS & LEGAL

MY LEGAL DOCUMENTS
...........................................................................\...20

MY INSURANCE
POLICIES............................................................................24

MY EMPLOYMENT
......................................................................................27

MY FINANCIAL INFORMATION
......................................................................30

MY REAL ESTATE
.......................................................................................34

MY UTILITIES
.............................................................................................35

MY VEHICLES
..........................................................................................\...37

# MISCELLANEOUS INFORMATION

MY PETS
...................................................................................................38

MY MEMBERSHIPS & CHARITIES
...............................................................\...39

# FINAL WISHES

FUNERAL ARRANGEMENTS
........................................................................40

NOTIFICATION IN CASE OF DEATH
............................................................\...43

**[BIBLIOGRAPHY &
RESOURCES]{.underline}**............................................................46

#### QUICK GUIDE TO LOCATION OF MY IMPORTANT DOCUMENTS

(Copy and paste more, if necessary.)

  ------------------------------------------- ---------------------------
  **DOCUMENT / ITEM**                         **LOCATION**

  Address book -- personal                    

  Address book -- professional                

  Adoption or legal guardianship papers       

  Bank account information -- check books,    
  statements, debit cards, ATM cards, etc.    

  Birth Certificate                           

  Credit cards -- cards, statements, etc.     

  Debts owed to me                            

  Deed                                        

  Disability records & insurance              

  Disposition of remains -- prepaid burial    
  plots, donor arrangements, etc.             

  Divorce papers                              

  Employment -- earnings & leave statements,  
  contracts, etc.                             

  Family tree & other information             

  Household effects inventory                 

  Income tax records                          

  Information on my inheritances              

  Insurance policy -- health                  

  Insurance policy -- life                    

  Insurance policy -- long term care          

  Insurance policy -- professional            

  Insurance policy -- property (mortgage,     
  homeowners, etc.)                           

  Insurance policy -- vehicle                 

  Investment records -- stocks, bonds, 401K,  
  IRA, etc.                                   

  Key -- safety deposit box                   

  Keys -- home                                

  Keys -- other properties                    

  Keys -- vehicles                            

  Keys or combination - P.O. Box              

  Lease                                       

  Marriage certificate                        

  Military service records                    

  Miscellaneous debts I owe                   

  Naturalization papers                       

  Passport                                    

  Pet records -- vaccination, medical, AKC    
  registration,etc.                           

  Power of attorney                           

  Social Security card                        

  Vaccination records                         

  Vehicle records -- loan, title,             
  registration, etc.                          

  Will, living will, etc.                     
  ------------------------------------------- ---------------------------

MY PERSONAL INFORMATION

FULL NAME:

MAIDEN NAME:

SOCIAL SECURITY NUMBER:

DATE OF BIRTH:

PLACE OF BIRTH *(include name of hospital, city, county, state,
country)*:

CURRENT HOME ADDRESS:

LOCATION OF HOUSE KEYS:

CURRENT MAILING ADDRESS:

LOCATION OF POST OFFICE BOX KEYS OR COMBINATION:

CURRENT STATE OF LEGAL RESIDENCE *(state in which I vote)*:

DRIVER'S LICENSE STATE & NUMBER:

HOME TELEPHONE:

CELLULAR TELEPHONE:

HOME FAX NUMBER:

PERSONAL E-MAIL ADDRESS(ES):

PERSONAL WEBSITE ADDRESS:

MARITAL STATUS:

TOTAL NUMBER OF BIOLOGICAL, ADOPTED, & STEPCHILDREN:

LOCATION OF MY PERSONAL ADDRESS BOOK:

LOCATION OF MY PROFESSIONAL ADDRESS BOOK:

LOCATION OF INFORMATION REGARDING FAMILY TREE & HISTORY:

**[MY MARITAL HISTORY]{.underline}**

## MY CURRENT MARRIAGE

NAME OF SPOUSE:

DATE & PLACE OF MARRIAGE:

LOCATION OF MARRIAGE CERTIFICATE:

SPOUSE'S SOCIAL SECURITY NUMBER:

SPOUSE'S DATE OF BIRTH:

SPOUSE'S PLACE OF BIRTH:

SPOUSE'S HOME ADDRESS:

SPOUSE'S HOME TELEPHONE:

SPOUSE'S E-MAIL ADDRESS:

SPOUSE'S PERSONAL WEBSITE ADDRESS:

SPOUSE'S EMPLOYER:

ADDRESS OF SPOUSE'S EMPLOYER:

SPOUSE'S WORK TELEPHONE:

SPOUSE'S E-MAIL ADDRESS:

NAME & TELEPHONE OF SPOUSE'S SUPERVISOR:

# MY PREVIOUS MARRIAGES

*(Copy and paste more, if necessary.)*

NAME OF FORMER SPOUSE:

DATE & PLACE OF MARRIAGE:

DATE & PLACE OF DIVORCE:

LOCATION OF DIVORCE PAPERS:

FORMER SPOUSE'S CURRENT HOME ADDRESS:

FORMER SPOUSE'S CURRENT HOME TELEPHONE:

FORMER SPOUSE'S CURRENT WORK TELEPHONE:

FORMER SPOUSE'S CURRENT E-MAIL ADDRESS:

# 

#  

# MY SPOUSE

NAME OF SPOUSE:

DATE & PLACE OF MARRIAGE:

LOCATION OF MARRIAGE CERTIFICATE:

SPOUSE'S SOCIAL SECURITY NUMBER:

SPOUSE'S DATE OF BIRTH:

SPOUSE'S PLACE OF BIRTH:

SPOUSE'S HOME ADDRESS:

SPOUSE'S HOME TELEPHONE:

SPOUSE'S E-MAIL ADDRESS:

SPOUSE'S PERSONAL WEBSITE ADDRESS:

SPOUSE'S EMPLOYER:

SPOUSE'S WORK TELEPHONE:

SPOUSE'S WORK E-MAIL ADDRESS:

ADDRESS OF SPOUSE'S EMPLOYER:

NAME & TELEPHONE OF SPOUSE'S SUPERVISOR:

## SPOUSE'S MARITAL HISTORY

*(Copy and paste more, if necessary.)*

NAME OF FORMER SPOUSE:

DATE & PLACE OF PREVIOUS MARRIAGE:

DATE & PLACE OF DIVORCE:

HOME ADDRESS OF FORMER SPOUSE:

HOME TELEPHONE OF FORMER SPOUSE:

WORK TELEPHONE OF FORMER SPOUSE:

# 

E-MAIL ADDRESS OF FORMER SPOUSE:

# SPOUSE'S CHILDREN WITH ME

*(Copy and paste more, if necessary.)*

NAME:

DATE OF BIRTH:

PLACE OF BIRTH:

SOCIAL SECURITY NUMBER:

ADDRESS:

TELEPHONE:

E-MAIL:

# SPOUSE'S CHILDREN BY PREVIOUS MARRIAGE

*(Copy and paste more, if necessary.)*

NAME:

DATE OF BIRTH:

PLACE OF BIRTH:

SOCIAL SECURITY NUMBER:

ADDRESS:

TELEPHONE:

E-MAIL:

## SPOUSE'S PARENTS

FATHER'S NAME:

DATE OF BIRTH:

PLACE OF BIRTH:

DATE OF DEATH:

PLACE OF BURIAL:

CAUSE OF DEATH:

SOCIAL SECURITY NUMBER:

ADDRESS:

HOME TELEPHONE:

WORK TELEPHONE:

CELLULAR TELEPHONE:

E-MAIL:

MOTHER'S NAME:

MOTHER'S MAIDEN NAME:

DATE OF BIRTH:

PLACE OF BIRTH:

DATE OF DEATH:

PLACE OF BURIAL:

CAUSE OF DEATH:

SOCIAL SECURITY NUMBER:

ADDRESS:

HOME TELEPHONE:

WORK TELEPHONE:

CELLULAR TELEPHONE:

E-MAIL:

## 

## SPOUSE'S SIBLINGS

*(Copy and paste more, if necessary.)*

NAME:

DATE OF BIRTH:

PLACE OF BIRTH:

SOCIAL SECURITY NUMBER:

ADDRESS:

HOME TELEPHONE:

WORK TELEPHONE:

CELLULAR TELEPHONE:

E-MAIL:

## SPOUSE'S GRANDCHILDREN

*(Copy and paste more, if necessary.)*

NAME:

DATE OF BIRTH:

PLACE OF BIRTH:

SOCIAL SECURITY NUMBER:

ADDRESS:

TELEPHONE:

E-MAIL:

**[MY FAMILY HISTORY]{.underline}**

## PARENTS

FATHER'S NAME:

DATE OF BIRTH:

PLACE OF BIRTH:

DATE OF DEATH:

PLACE OF BURIAL:

CAUSE OF DEATH:

SOCIAL SECURITY NUMBER:

ADDRESS:

HOME TELEPHONE:

WORK TELEPHONE:

CELLULAR TELEPHONE:

E-MAIL:

MOTHER'S NAME:

MOTHER'S MAIDEN NAME:

DATE OF BIRTH:

PLACE OF BIRTH:

DATE OF DEATH:

PLACE OF BURIAL:

CAUSE OF DEATH:

SOCIAL SECURITY NUMBER:

ADDRESS:

HOME TELEPHONE:

WORK TELEPHONE:

CELLULAR TELEPHONE:

E-MAIL:

## SIBLINGS

*(Copy and paste more, if necessary.)*

NAME:

DATE OF BIRTH:

PLACE OF BIRTH:

SOCIAL SECURITY NUMBER:

ADDRESS:

HOME TELEPHONE:

WORK TELEPHONE:

CELLULAR TELEPHONE:

E-MAIL:

# MY CHILDREN

*(Copy and paste more, if necessary.)*

NAME:

DATE OF BIRTH:

PLACE OF BIRTH:

SOCIAL SECURITY NUMBER:

CURRENT ADDRESS:

CURRENT TELEPHONE:

E-MAIL:

## GRANDCHILDREN

*(Copy and paste more, if necessary.)*

NAME:

DATE OF BIRTH:

PLACE OF BIRTH:

SOCIAL SECURITY NUMBER:

ADDRESS:

TELEPHONE:

E-MAIL:

## 

**[MEDICAL INFORMATION]{.underline}**

**[BLOOD TYPE]{.underline}**

MY BLOOD TYPE

MY SPOUSE'S BLOOD TYPE

MY CHILDREN'S BLOOD TYPES

**[MEDICATIONS]{.underline}**

*(Include eyeglasses, if applicable. Copy and paste more, if
necessary.)*

MY MEDICATIONS

> NAME OF MEDICINE:
>
> DOCTOR PRESCRIBING:
>
> PRESCRIPTION NUMBER:
>
> DOSAGE:

MY SPOUSE'S MEDICATIONS

> NAME OF MEDICINE:
>
> DOCTOR PRESCRIBING:
>
> PRESCRIPTION NUMBER:
>
> DOSAGE:

MY CHILDREN'S MEDICATIONS

> NAME OF MEDICINE:
>
> DOCTOR PRESCRIBING:
>
> PRESCRIPTION NUMBER:
>
> DOSAGE:

**[ALLERGIES]{.underline}**

MY ALLERGIES

MY SPOUSE'S ALLERGIES

MY CHILDREN'S ALLERGIES

**[VACCINATION RECORDS]{.underline}**

LOCATION OF MY RECORDS:

LOCATION OF MY SPOUSE'S RECORDS:

LOCATION OF CHILDREN'S RECORDS:

**[HOSPITAL]{.underline}**

HOSPITAL NEAREST MY HOME *(include name & address)*:

HOSPITAL I PREFER *(include name & address)*:

**[MISCELLANEOUS]{.underline}**

MEDICARE NUMBERS:

MEDICAID NUMBERS:

CASEWORKER NUMBERS, ADDRESS/TELEPHONE):

SOCIAL WORKER OR CASEWORKER NAMES & CONTACT INFO:

**[GENERAL PRACTITIONER]{.underline}**

NAME:

ADDRESS:

TELEPHONE:

E-MAIL:

**[DENTIST]{.underline}**

NAME:

ADDRESS:

TELEPHONE:

E-MAIL:

**[OTHER DOCTORS]{.underline}**

*(Copy and paste more, if necessary.)*

NAME:

TYPE OF DOCTOR:

ADDRESS:

TELEPHONE:

E-MAIL:

**[TO NOTIFY IN CASE OF EMERGENCY]{.underline}**

*(Include family and business contacts. Copy and paste more, if
necessary.)*

NAME:

HOME TELEPHONE:

WORK TELEPHONE:

RELATIONSHIP:

ADDRESS:

E-MAIL:

NAME:

HOME TELEPHONE:

WORK TELEPHONE:

RELATIONSHIP:

ADDRESS:

E-MAIL:

NAME:

HOME TELEPHONE:

WORK TELEPHONE:

RELATIONSHIP:

ADDRESS:

E-MAIL:

**[MY LEGAL DOCUMENTS]{.underline}**

**[SOCIAL SECURITY]{.underline}**

NUMBER:

LOCATION OF CARD:

**[PASSPORT & NATURALIZATION PAPERS]{.underline}**

MY PASSPORT NUMBER:

LOCATION OF MY PASSPORT:

PASSPORT NUMBERS OF FAMILY MEMBERS:

*(Copy and paste more, if necessary.)*

> NAME:
>
> NUMBER:
>
> LOCATION:

DATE OF MY NATURALIZATION:

LOCATION OF MY NATURALIZATION PAPERS:

NATURALIZATION OF FAMILY MEMBERS:

*(Copy and paste more, if necessary.)*

> NAME:
>
> DATE:
>
> LOCATION:

**[BIRTH & ADOPTION CERTIFICATES]{.underline}**

LOCATION OF MY BIRTH CERTIFICATE:

LOCATION OF SPOUSE'S & CHILDRENS' CERTIFICATES:

**[WILL]{.underline}**

DATE:

LOCATION:

EXECUTOR:

ATTORNEY:

> LAW FIRM:
>
> ADDRESS:
>
> TELEPHONE:

**[OTHER DOCUMENTS]{.underline}** *(living will, advance directive,
"Five Wishes," DNR, etc.)*

LOCATION OF DOCUMENTS:

MY "HEALTH CARE AGENTS"

> FIRST CHOICE NAME:
>
> ADDRESS:
>
> TELEPHONE:
>
> SECOND CHOICE NAME:
>
> ADDRESS:
>
> TELEPHONE:

**[POWER OF ATTORNEY]{.underline}**

*(Copy and paste more, if necessary.)*

WHO HAS MY POWER OF ATTORNEY?

LOCATION OF (ORIGINAL) POWER OF ATTORNEY DOCUMENTS:

**[LEGAL GUARDIANSHIP]{.underline}**

NAME OF PERSON FOR WHOM I HAVE LEGAL GUARDIANSHIP:

LOCATION OF DOCUMENT:

ATTORNEY:

> LAW FIRM:
>
> ADDRESS:
>
> TELEPHONE:

**[TRUST FUNDS]{.underline}**

*(Copy and paste more, if necessary.)*

TYPE:

BENEFICIARY

ATTORNEY:

> LAW FIRM:
>
> ADDRESS:
>
> TELEPHONE:

**[INHERITANCE]{.underline}**

DETAILS REGARDING INHERITANCES DUE TO ME:

LOCATION OF RELEVANT DOCUMENTS:

**[LEASE]{.underline}**

*(Copy and paste more, if necessary.)*

NAME OF LESSOR:

ADDRESS:

TELEPHONE:

ADDRESS OF RENTED PROPERTY:

TYPE OF PROPERTY *(apartment, vacation cottage, house, stable, etc.)*:

RENT *(include amount & due date)*:

EXPIRATION DATE:

LOCATION OF LEASE DOCUMENT:

**[HOUSEHOLD EFFECTS INVENTORY]{.underline}**

LOCATION OF INVENTORY LIST *(including list of jewelry & valuables)*:

ITEMS IN STORAGE *(include inventory; storage bin number; name & address
of storage company & amount of monthly payment; & any insurance
coverage)*:

**[MY INSURANCE POLICIES]{.underline}**

## HEALTH INSURANCE

COMPANY:

ADDRESS:

FEDERAL PLAN?

MEMBER NUMBER:

GROUP POLICY NUMBER:

PERSONS COVERED:

ADDITIONAL COVERAGE:

PAYMENT *(include amount & due date, if not deducted automatically from
salary)*:

LOCATION OF POLICY:

MEDICARE NUMBERS:

MEDICAID NUMBERS:

CASEWORKER NUMBERS, ADDRESS/TELEPHONE):

**[LONG TERM CARE INSURANCE]{.underline}**

COMPANY:

ADDRESS:

POLICY NUMBER:

PAYMENT *(include amount & due date)*:

LOCATION OF POLICY:

## LIFE INSURANCE

COMPANY:

AMOUNT:

BENEFICIARY:

LOCATION OF POLICY:

SPOUSE'S LIFE INSURANCE POLICY & COMPANY:

POLICIES ON SPOUSE & CHILDREN:

PAYMENT *(include amount & due date)*:

LOCATION OF POLICY:

**[DISABILITY INSURANCE]{.underline}**

NAME:

ADDRESS:

MEMBER NUMBER:

LOCATION OF POLICY:

**[PROFESSIONAL INSURANCE]{.underline}**

COMPANY:

ADDRESS:

MEMBER NUMBER:

GROUP POLICY NUMBER:

PAYMENT *(include amount & due date)*:

LOCATION OF POLICY:

**[PROPERTY INSURANCE]{.underline}**

*(Copy and paste more, if necessary.)*

MORTGAGE INSURANCE COMPANY:

POLICY NUMBER:

ADDRESS:

PAYMENT *(include amount & due date)*:

LOCATION OF MORTGAGE INSURANCE POLICY:

HOMEOWNER'S INSURANCE COMPANY:

POLICY NUMBER:

ADDRESS:

PAYMENT *(include amount & due date)*:

LOCATION OF HOMEOWNER'S INSURANCE POLICY:

**[VEHICLE INSURANCE]{.underline}**

*(Copy and paste more, if necessary.)*

COMPANY:

ADDRESS:

POLICY NUMBER:

PAYMENT *(include amount & due date)*:

LOCATION OF POLICY:

### MY EMPLOYMENT

## CURRENT EMPLOYER / BUSINESS

*(Copy and paste more, if necessary.)*

## 

NAME OF EMPLOYER:

NAME OF OFFICE:

## ADDRESS:

MY WORK TELEPHONE:

MY WORK E-MAIL ADDRESS:

DATES OF MY EMPLOYMENT:

MY CURRENT TITLE:

MY CURRENT RANK:

NAME OF SUPERVISOR:

## 

## TELEPHONE OF SUPERVISOR:

E-MAIL OF SUPERVISOR:

BUSINESS LICENSE INFORMATION:

## SALARY

ANNUAL SALARY:

FREQUENCY OF PAYMENT:

AUTOMATIC DEDUCTIONS *(include account & amount)*:

LOCATION OF EARNINGS & LEAVE STATEMENTS:

## LEAVE PROGRAM

ANNUAL LEAVE BALANCE:

SICK LEAVE BALANCE:

HOME LEAVE BALANCE:

MEMBER OF A MEDICAL LEAVE SHARING PLAN?

BENEFICIARY:

## PREVIOUS EMPLOYMENT

LOCATION OF RECORDS OF PREVIOUS EMPLOYMENT:

## RETIREMENT

RETIREMENT SYSTEM:

DATE OF ELIGIBILITY FOR RETIREMENT:

DUE TO PRIOR MILITARY SERVICE OR FEDERAL SERVICE, I HAVE BEEN ADVISED
THAT I MAY NEED TO PAY EITHER A DEPOSIT OR A RE-DEPOSIT TO FULLY RECEIVE
CREDIT FOR THAT SERVICE: YES NO

HAVE DEPOSITS/RE-DEPOSITS BEEN PAID? YES NO

IF MY DEATH OCCURS BEFORE RETIREMENT, MY SPOUSE IS AWARE THAT S/HE MAY
BE ELIGIBLE FOR A SURVIVOR ANNUITY? YES NO

AMOUNT PER MONTH:

RESTRICTIONS/LIMITATIONS:

IF I AM A FEDERAL EMPLOYEE UNDER FERS, IS MY SPOUSE AWARE S/HE & THE
CHILDREN MAY QUALIFY FOR SOCIAL SECURITY BENEFITS? YES NO

## MY MILITARY SERVICE

MILITARY ID NUMBER:

BRANCH OF SERVICE:

YEARS OF SERVICE:

RANK AT SEPARATION:

LOCATION OF RECORD OF MILITARY SERVICE (DD 214):

**[MY FINANCIAL INFORMATION]{.underline}**

## BANK ACCOUNTS

*(Copy and paste more, if necessary.)*

BANK:

ADDRESS:

CHECKING ACCOUNT NUMBER:

IS THIS A JOINT ACCOUNT? WITH WHOM?

IS THERE A DEBTOR CARD(S) ISSUED ON THIS ACCOUNT?

SAVINGS ACCOUNT NUMBER:

> IS THIS A JOINT ACCOUNT? WITH WHOM?

ATM CARD NUMBER & PIN NUMBER:

LOCATION OF CHECKBOOKS, STATEMENTS, & OTHER INFO:

## INVESTMENTS:

*(Copy and paste more, if necessary. Include IRAs, TSP/401Ks,
Certificates of Deposit, Stocks, Bonds, etc.)*

ACCOUNT NUMBER:

TYPE:

COMPANY:

BENEFICIARY:

LOCATION OF RECORDS:

## SAFETY DEPOSIT BOX

SAFETY DEPOSIT BOX NUMBER:

BANK:

ADDRESS:

ACCESSIBLE BY:

LOCATION OF KEY:

CONTENTS:

## 

## CREDIT CARDS

*(Copy and paste more, if necessary.)*

NAME:

ACCOUNT NUMBER:

PIN NUMBER:

ISSUED BY:

ADDRESS:

IS ACCOUNT BALANCE INSURED?

LOCATION OF STATEMENTS & OTHER INFO:

## FINANCIAL ADVISOR / PLANNER / MANAGER / ACCOUNTANT

*(Copy and paste more, if necessary.)*

NAME & TITLE:

NAME OF BUSINESS:

ADDRESS:

TELEPHONE:

E-MAIL:

## RECORDS OF OTHER DEBTS OWED BY ME

*(Copy and paste more, if necessary.)*

DEBT OWED TO:

ADDRESS:

TELEPHONE:

TYPE OF DEBT:

AMOUNT:

DUE DATE:

LOCATION OF DOCUMENTATION:

## RECORDS OF ANY DEBT OWED TO ME

*(Copy and paste more, if necessary.)*

NAME OF DEBTOR:

ADDRESS:

TELEPHONE:

TYPE OF DEBT:

AMOUNT:

DUE DATE:

LOCATION OF DOCUMENTATION:

## INCOME TAXES

LOCATION OF TAX RETURNS/RECORDS:

NAME & ADDRESS OF TAX PREPARER:

## FINANCIAL INFORMATION OF SPOUSE & CHILDREN

**[MY REAL ESTATE]{.underline}**

*(Copy and paste more, if necessary.)*

TYPE OF PROPERTY *(stand alone house? apartment? townhouse? warehouse?
office building? other?)*:

JOINT OWNERSHIP?

ADDRESS:

LOCATION OF DEED:

VALUE OF PROPERTY:

PROPERTY MANAGEMENT COMPANY:

MORTGAGE ON THE PROPERTY IS HELD BY:

ADDRESS:

BALANCE OF LOAN:

MONTHLY PAYMENT *(amount & due date)*:

LOCATION OF MORTGAGE & TAX PAYMENT DOCUMENTS & RECEIPTS:

MORTGAGE INSURANCE:

LOCATION OF MORTGAGE INSURANCE POLICY:

HOMEOWNER'S INSURANCE HELD BY:

LOCATION OF HOMEOWNER'S INSURANCE POLICY:

**[UTILITIES]{.underline}**

*(Copy and paste more, if necessary.)*

**[ADDRESS WHERE PAID:]{.underline}**

> **[ELECTRICITY]{.underline}**
>
> COMPANY:
>
> ACCOUNT NUMBER:
>
> **[WATER]{.underline}**
>
> COMPANY:
>
> ACCOUNT NUMBER:
>
> **[GAS]{.underline}**
>
> COMPANY:
>
> ACCOUNT NUMBER:
>
> **[TELEPHONES]{.underline}**
>
> COMPANY:
>
> ACCOUNT NUMBER:
>
> TELEPHONE NUMBER:
>
> COMPANY:
>
> ACCOUNT NUMBER:
>
> TELEPHONE NUMBER:

**[NEWSPAPER]{.underline}**

COMPANY:

ACCOUNT NUMBER:

**[INTERNET SERVICE]{.underline}**

COMPANY:

ACCOUNT NUMBER:

LOGON NAME:

PASSWORD:

**[CABLE TELEVISION]{.underline}**

COMPANY:

ACCOUNT NUMBER:

LOGON NAME:

PASSWORD:

**[OTHER SUBSCRIPTIONS]{.underline}**

*(Copy and paste more, if necessary.)*

COMPANY:

ACCOUNT NUMBER:

LOGON NAME:

PASSWORD:

**[MY VEHICLES]{.underline}**

*(Copy and paste more, if necessary.)*

TYPE *(sedan? SUV? truck? minivan? other?)*:

MAKE:

MODEL:

YEAR:

REGISTERED TO *(include location of registration document)*:

STATUS OF OWNERSHIP *(lien? own? lease?)*:

> BANK/CREDITOR THAT HANDLES LOAN:
>
> ADDRESS:
>
> PAYMENT *(amount & due date)*:
>
> BALANCE:

LOCATION OF LOAN PAPERS & INVOICES:

VIN NUMBER:

LICENSE PLATE NUMBER:

LOCATION OF TITLE:

LOCATION OF EXTRA KEYS:

INSURED BY:

ADDRESS OF INSURANCE COMPANY:

INSURANCE POLICY NUMBER:

LOCATION OF INSURANCE POLICY:

**[MY PETS]{.underline}**

*(Copy and paste more, if necessary.)*

NAME:

TYPE:

BREED:

SEX: MALE FEMALE

NEUTERED? YES NO

DATE OF BIRTH:

MEDICAL PROBLEMS:

DIET:

SPECIAL NEEDS:

LOCATION OF RECORDS (vaccination, AKC registration, etc.):

DISPOSITION IN CASE OF MY DEATH:

**[VETERINARIAN]{.underline}**

NAME:

ADDRESS:

TELEPHONE:

E-MAIL:

**[PET INSURANCE]{.underline}**

COMPANY:

POLICY NUMBER:

ADDRESS:

TELEPHONE:

**[MY MEMBERSHIPS & CHARITIES]{.underline}**

(Include professional and recreational memberships. Copy and paste more,
if necessary.)

NAME OF ORGANIZATION:

ADDRESS:

TELEPHONE:

MY MEMBERSHIP NUMBER:

NAME OF ORGANIZATION:

ADDRESS:

TELEPHONE:

MY MEMBERSHIP NUMBER:

NAME OF ORGANIZATION:

ADDRESS:

TELEPHONE:

MY MEMBERSHIP NUMBER:

NAME OF ORGANIZATION:

ADDRESS:

TELEPHONE:

MY MEMBERSHIP NUMBER:

**[FUNERAL ARRANGEMENTS]{.underline}**

RELIGIOUS AFFILIATION:

CHURCH:

ADDRESS:

TELEPHONE:

**[FUNERAL SERVICES]{.underline}**

TYPE OF SERVICE:

PLACE:

TIME:

CLERGY:

> ADDRESS:
>
> TELEPHONE:

E-MAIL:

SPECIAL REQUESTS FOR SERVICE *(music, flowers, readings, etc.)*:

AM I ENTITLED TO MILITARY HONORS? YES NO

WHO WOULD I LIKE TO DO THE EULOGY?

> ADDRESS:
>
> TELEPHONE:

E-MAIL:

WHO WOULD I ESPECIALLY LIKE TO ATTEND?

**[OBITUARY]{.underline}**

DO I WANT AN OBITUARY PUBLISHED?

WHERE?

WHAT I WANT INCLUDED IN THE OBITUARY:

**[DISPOSITION OF REMAINS]{.underline}**

ORGAN DONOR? YES NO

SPECIAL INSTRUCTIONS FOR ORGAN DONATION:

FUNERAL HOME PREFERENCE:

ADDRESS:

TELEPHONE:

BURIAL *(casket, vault, crypt)*?

MY CHOICE OF CEMETARY:

> PRE-PAID BURIAL PLAN?
>
> LOCATION OF PLAN:

CLOTHING TO BE BURIED IN:

PALLBEARERS: *(Copy and paste more, if necessary.)*

> NAME:
>
> ADDRESS:
>
> TELEPHONE:

CREMATION?

WHAT I WOULD LIKE DONE WITH MY ASHES:

DONATION OF BODY?

> ORGANIZATION TO RECEIVE MY REMAINS:
>
> ARRANGEMENTS MADE FOR THIS IN ADVANCE:
>
> LOCATION OF DOCUMENTS:

**[TO NOTIFY IN CASE OF DEATH]{.underline}**

*(Copy and paste more, if necessary. Include family and business
contacts.)*

NAME:

HOME TELEPHONE:

WORK TELEPHONE:

RELATIONSHIP:

ADDRESS:

E-MAIL:

NAME:

HOME TELEPHONE:

\\WORK TELEPHONE:

RELATIONSHIP:

ADDRESS:

E-MAIL:

NAME:

HOME TELEPHONE:

WORK TELEPHONE:

RELATIONSHIP:

ADDRESS:

E-MAIL:

**[ALSO NOTIFY:]{.underline}**

(Names & contact details listed in other sections.)

\_\_\_\_\_ EMPLOYER(S)

\_\_\_\_\_ DOCTOR(S)

\_\_\_\_\_ RELATIVES & FRIENDS IN ADDRESS BOOK & E-MAIL ADDRESS BOOK

\_\_\_\_\_ ATTORNEY

\_\_\_\_\_ ACCOUNTANT / FINANCIAL MANAGER

\_\_\_\_\_ BANK(S)

\_\_\_\_\_ BROKER(S)

\_\_\_\_\_ INSURANCE COMPANIES

\_\_\_\_\_ ORGANIZATIONS OF WHICH I AM A MEMBER

\_\_\_\_\_ OTHER
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_ OTHER
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_ OTHER
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_ OTHER
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_ OTHER
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**[BIBLIOGRAPHY & RESOURCES]{.underline}**

Aging With Dignity (Five Wishes) -
[www.agingwithdignity.org](http://www.agingwithdignity.org/)

American Bar Association -
[www.abanet.org/aging/](http://www.abanet.org/aging/)

American Association of Retired People -
[www.aarp.org](http://www.aarp.org/)

"The F.I.L.E." published by the Baltimore County Department of Aging in
1997

[Life and Death Preparation Kit]{.underline} published by Compass Home
Page ([www.willprepkit.com/](http://www.willprepkit.com/)) for \$19.95

McPhelimy, Lynn; [In the Checklist of Life -- A Working Book To Help You
Live and Leave This Life!]{.underline}

The Medical Directive -
[www.medicaldirective.org](http://www.medicaldirective.org/)

Oishi, Emily and Thompson, Sue; [Before It's Too Late: Don't Leave Your
Loved Ones Unprepared]{.underline}

Partnership for Caring -
[www.partnershipforcaring.org](http://www.partnershipforcaring.org/)

"Personal Affairs Record Book" published by the Council for Court
Excellence in February 2002 and printed as a public service by GEICO

"Personal Records" published by the USAA Educational Foundation in 2001

Todd, Elaine and Schultz, Alan D.; [All Together Now: Records,
Instructions and Wishes for Those You Love]{.underline}

"What My Family Should Know: A Guide For Getting Your Affairs In Order"
published by the National Guard Family Program