By Family Caregiver Alliance
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 |
My will (original) | | | |
Power of attorney--healthcare | | | |
Power of attorney--finance | | | |
Spouse's/Partner's Will (original) | | | |
Safe combination | | | |
Trust agreement | | | |
Life insurance policy | | | |
Health insurance policy | | | |
Homeowners policy | | | |
Car insurance policy | | | |
Employment contracts | | | |
Partnership agreements | | | |
List of checking, saving accounts | | | |
List of credit cards | | | |
Retirement papers | | | |
Deferred compensation; IRA | | | |
Funeral arrangements | | | |
Titles and deeds | | | |
Notes (mortgages) | | | |
List of stored & loaned items | | | |
Auto ownership records | | | |
Birth certificate | | | |
Military/veterans papers | | | |
Marriage certificate | | | |
Children's birth certificates | | | |
Divorce/separation records | | | |
Other | | | |
Other | | | |
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.
This article was created by Family Caregiver Alliance. Reprinted with permission. To learn more about Family Caregiver Alliance (FCA), go to www.caregiver.org