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Name: _________________________________________________
Social Security No.: _______________________________________
Spouse's/Partner's Name: ___________________________________
Social Security No.: _______________________________________
Address: _______________________________________________
Date Prepared: ___________________________________________
Copies Given to: __________________________________________
My valuable papers are stored in these locations
(address and where to look):
A: Residence____________________________________________
B: Safe Deposit Box ____________________________________
C: Other ______________________________________________ |
| Item |
A |
B |
C |
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My will (original)
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Power of attorney--healthcare
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Power of attorney--finance
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Spouse's/Partner's Will (original)
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Safe combination
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Trust agreement
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Life insurance policy
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Health insurance policy
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Homeowners policy
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Car insurance policy
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Employment contracts
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Partnership agreements
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List of checking, saving accounts
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List of credit cards
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Retirement papers
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Deferred compensation; IRA
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Funeral arrangements
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Titles and deeds
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Notes (mortgages)
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List of stored & loaned items
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Auto ownership records
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Birth certificate
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Military/veterans papers
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Marriage certificate
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Children's birth certificates
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Divorce/separation records
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Other
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Other
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Important Names, Addresses, and Phone Numbers
Emergency Contact: ________________________________________
Doctor(s): _______________________________________________
Clergy: __________________________________________________
Attorney: ________________________________________________
Accountant: ______________________________________________
Insurance Agent: __________________________________________
Reproduced with permission of Mountain Caregiver Resource Center/Janet Levy Center. Family Caregiver Alliance and Mountain CRC are part of a statewide system of regional resource centers serving families and caregivers of brain-impaired adults.
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