PERSONAL DATA SUMMARY

Your wishes are important!  Please complete this document to be sure they’re known, and to help your loved ones and your executor/executrix carry them out for you.  Please keep this form in a prominent place and give a copy to the executor of your will.
(If more space is needed for any question, please use the reverse of this page or attach a separate sheet of paper.)

INFORMATION ABOUT YOU
1.	 Print your FULL name, including any middle name/s you were given at birth.  If you have ever been known by any other name, please explain.

2.	What is the date and place of your birth?  If you have naturalization papers, where are they located?

3.	Where do you keep copies of your birth certificate?  If there are adoption papers, for you or for a child of yours, where are they located?

4.	What are the names of your parents?

5.	In what cities have you been a resident?  Give approximate dates of residence there, if available.

6.	If you are or have been married, where is your marriage certificate?  If you have ever been divorced, where is the divorce decree?

7.	What is your Social Security Number?

YOUR LEGAL AFFAIRS

8.	Who is your lawyer?  Please write his name, the name of his firm, his address, and his phone number.  (If you use more than one lawyer, please list all.)

9.	Do you have a will?  If so, who has the signed original “conformed copy” of that will?

10.	Where is your copy of your will?

11.	Who else has a copy of your will?

12.	Who is the Executor of your will?  Provide his/her address and telephone number

13.	Have you created and signed a Power of Attorney?  If so, who is named and where are any copies?

14.	Do you have a Living Will and/or Health Care Proxy?  If so, where are they located?

OTHER PEOPLE WHO HAVE ASSISTED YOU

15.	Who is your stockbroker or investment advisor and his firm?

16.	Who is your accountant or tax preparer, if any?

17.	Who is your bank trust officer, if any?

18.	Who are your usual doctors?

19.	Are any important medical records located elsewhere?  (with another doctor or at a hospital)

20.	Is there anyone not already mentioned who assists you in managing your affairs?

YOUR BUSINESS AND FINANCIAL AFFAIRS
21.	At what banks or credit unions do you have accounts?

22.	Where are your bankbooks and/or statements?

23.	Where do you usually keep your checkbook?

24.	Do you have a Safe Deposit Box?  If so, where is it located?

25.	Where is the key for the Safe Deposit Box?

26.	Do you own any securities?  If so, where are they kept?

27.	Are you involved in any dividend reinvestment plans?  If so, what are the companies and where are the latest statements?

28.	What is the usual location of your:

a. Securities records

b. Tax return copies

c. Mortgage  payment books/records

d. Car payment books/records

e. Automobile Registrations

f. Automobile Titles

g. Driver’s License

h. Other ID cards, or numbers, e.g. Passport, Veterans Administration claim number, information about membership in major organizations

i. Current bills due payment

j. Credit cards

k. Canceled checks

l. Evidence of paid bills for major household improvements

29.	Other than any locations listed above, is there any other place that should be checked for its contents?

30.	Are you a member of any organization that might present a bill for a payment that is due?  

31.	Is there any item of yours that is kept at a club location and should be recovered? (i.e., golf clubs)  Is there any item belonging to the club which is in your possession and should be returned to them?  Is there a club membership which could be passed on to your heirs or sold?

32.	Are you the recipient of any benefits such as Social Security, Veterans, Railroad, etc.?  If so, how are these received, as in via a direct deposit or at your home?  

33.	Do you have 401(k) or IRA accounts?  Please indicate their location(s) and the named beneficiaries.

34.	Are you the beneficiary of any trusts?  If so, please identify the trustee, benefits you receive, and any terms thereof.  Do you have any powers, dispositive or other, with respect to such trusts?

35.	Are there any sources of income that have not been mentioned?  Name any company that pays or owes you wages, any pension source, retirement plan.  If you are a military veteran, list the location and telephone number of your Veterans Affairs and Retirement Services Office. 

36.	Have you created any trusts?  If so, list all available particulars, including responsible parties: trustee, trust officer.

37.	Do you have information (business, personal, family, financial etc.) in a computer or on computer disks that should be retrieved or destroyed?  If so, please explain.  Would you like to name a particular person to carry out your wishes regarding this data?

INSURANCE

38.	What medical or dental insurance do you have?  Please list the carrier and the policy number. (Include Medicare and appropriate number, when applicable.  If your Medicare number is a deceased spouse’s Social Security number, please say so here.)

39.	Do you have life insurance policies?  If so, who are the carriers and who are the named beneficiaries?

40.	What other forms of insurance do you have?  (House, Car, Personal Property, Personal Liability, Renters, any other)  Please list the carriers and the policy numbers.

YOUR PROPERTY

41.	What real estate do you own? (Indicate whether land, or buildings and land; give complete address; include any cemetery plot.)

42.	Where are the Deeds of Ownership for any real estate listed above?

43.	If you have a security system for your home or any other property, name the company that provided the system.  They should know the combination and have keys.  Do NOT list a secret pass number here, but if there is anyone to whom you have given the number, please write his name here.

44.	Is there any property that you rent, such as a house, storage unit, post office box, or anything else?  If so, where do you keep records of payments, and is there a refundable deposit on anything you rent?

45.	Is there any other important information not mentioned elsewhere in this form (Include evidence of outstanding debts, money owed to you, the combination for opening a safe, information about treasured possessions or collections, etc.)

YOUR WISHES

46.	In the event of your death, who should be notified?  Family, friends, business people, etc.  Include addresses or phone numbers for each.(Please write these names on a separate piece of paper and attach to this form.) 

47.	List any relatives that are living, other than those mentioned above.  Include their addresses if possible, their relationship to you, and important particulars that your executor should know about them.

48.	If you have any pets, please describe them, write down their names and food preferences, the name of their veterinarian, and identify anyone who may want your pet.

49.	Are there any of your possessions, other than those listed in your will, that you would like to direct to anyone?  (Please be specific, and list below or provide separate sheet.)

50.	In the event of your death, what are your wishes regarding burial, cremation, choice of funeral home, clergyman, and service, including music? If you have set aside any money for this, or prepaid for any part of it, please explain.  If you would like to name a charity for donations in lieu of flowers, please do so. If you would like to be an Organ Donor, where are any signed documents explaining your wishes?  

51.	What would you like included in your obituary notices?

52.	In what newspapers do you want the obituary?

53.	Would you like to write it yourself?  If so, attach to this form.

50.	Are there any other matters you would like your executor to know?

PLEASE KEEP THIS FORM IN A PROMINENT PLACE AND
GIVE A COPY TO YOUR EXECUTOR

Copyright    - PatriBenDa Publications, 1995(Rev. January, 1998)
Herrick Road, Boxford, Mass.  01921
(978) 887-8143
All rights reserved.  Reproduction or transmission in any form,
mechanical or electronic, is prohibited (except for personal
use) without permission in writing from the publisher.