PERSONAL RECORDS
of____________________________________
A RESIDENT OF THE
STATE OF MICHIGAN
Your name _______________________________________________________________
Address _________________________________________________________________
________________________________________________________________________
Telephone no. ____________________________________________________________
Date completed ___________________________________________________________
Where Important Papers May Be Found
YOUR WILL
Do you have a will? _______________________________________________________________
My will is kept ___________________________________________________________________
Personal representative ____________________________________________________________
Address
________________________________________________________________________
_______________________________________________________________________________
Lawyer ________________________________________________________________________
Address ________________________________________________________________________
_______________________________________________________________________________
Date of will _____________________________________________________________________
The date is important. If your will is OLD, you may also wish to review it in the light of changed circumstances such as: marriage; divorce; change in state or federal law; change of residence; unavailability of witnesses; or death, age, or failing powers of the person named as personal representative.
REMEMBER: If you do not have a will, your estate will be distributed as provided by stated law. Its formula for distribution may not be the same as you would want. Your wishes and your family’s special needs can best be satisfied if you make a will.
REAL ESTATE
Do you own real estate? ________________Home ________________Other________________
For each piece of real estate you own:
Real Estate #1Is title to the property in your name alone or in joint names? _______________________
Is there a mortgage on the property? __________________________________________
Who holds the mortgage? __________________________________________________
Address ________________________________________________________________
_______________________________________________________________________
The deed, a copy of the mortgage, survey, title insurance policy, and closing documents are kept
_______________________________________________________________________
Real Estate #1 (Continued)
Real estate tax receipts are kept _____________________________________________
Do you have fire insurance? ________________________________________________
Do you have liability insurance? _____________________________________________
Policies are kept __________________________________________________________
For advice as to keeping or selling the property, consult ___________________________
Address _________________________________________________________________
________________________________________________________________________
Real Estate #2
Is title to the property in your name alone or in joint names? _______________________
Is there a mortgage on the property? __________________________________________
Who holds the mortgage? __________________________________________________
Address ________________________________________________________________
_______________________________________________________________________
The deed, a copy of the mortgage, survey, title insurance policy, and closing documents are kept
_____________________________________________________________________
Real estate tax receipts are kept _____________________________________________
Do you have fire insurance? ________________________________________________
Do you have liability insurance? _____________________________________________
Policies are kept __________________________________________________________
For advice as to keeping or selling the property, consult ___________________________
Address _________________________________________________________________
________________________________________________________________________
Real Estate #3
Is title to the property in your name alone or in joint names? _______________________
Is there a mortgage on the property? __________________________________________
Who holds the mortgage? __________________________________________________
Address ________________________________________________________________
_______________________________________________________________________
The deed, a copy of the mortgage, survey, title insurance policy, and closing documents are kept
_______________________________________________________________________
Real estate tax receipts are kept _____________________________________________
Do you have fire insurance? ________________________________________________
Do you have liability insurance? _____________________________________________
Policies are kept __________________________________________________________
For advice as to keeping or selling the property, consult ___________________________
Address _________________________________________________________________
________________________________________________________________________
Additional notes
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
LIFE INSURANCE
Do you have insurance? ____________________________________________________
Company _______________________ Policy No. _______________________________
Is the life insurance in trust? _________________________________________________
Trustee __________________________________________________________________
Address _________________________________________________________________
________________________________________________________________________
Who is the beneficiary? ____________________________________________________
Policies are kept __________________________________________________________
Any unpaid loans secured by policies? _________________________________________
Who is the lender? _________________________________________________________
Insurance advisor __________________________________________________________
Address __________________________________________________________________
_________________________________________________________________________
MILITARY, FRATERNAL OR COMPANY INSURANCE
Do you have military, fraternal, or company insurance? ____________________________
Company _________________________ Policy No. ______________________________
Who is the beneficiary? _____________________________________________________
Is the life insurance in trust? _________________________________________________
Address _________________________________________________________________
________________________________________________________________________
Policies are kept __________________________________________________________
Any unpaid loans secured by policies? ________________________________________
Who is the leader? ________________________________________________________
Insurance advisor _________________________________________________________
Address _________________________________________________________________
________________________________________________________________________
OTHER PERSONAL INSURANCE – Do you have:
Health and accident insurance? _____________________________________________________
Company _______________________________________________________________
Policy No. ______________________________________________________________
Hospitalization insurance? _________________________________________________________
Company _______________________________________________________________
Policy No. ______________________________________________________________
Insurance for medical and surgical expenses? __________________________________________
Company _______________________________________________________________
Policies are kept __________________________________________________________
SOCIAL SECURITY
Social Security No. _______________________________________________________
Card is kept _____________________________________________________________
Employment record is kept _________________________________________________
PENSION AND RETIREMENT INFORMATION
Do you have a pension or other retirement program? _____________________________
No. __________________ Is there a survivor benefit? ____________________________
Contact _________________________________________________________________
Address ________________________________________________________________
FAMILY RECORDS
Born in _________________________________________________________________
Date ____________________________________________________________________
Married in _______________________________________________________________
Date ____________________________________________________________________
When are birth certificates (or other proof of dates of birth) of members of family, marriage certificates, any naturalization papers, or discharge papers and other data as to military service?
________________________________________________________________________
________________________________________________________________________
BANK RECORDS
Do you have a checking account(s)? __________________________________________
Where is/are your checking account(s)? _______________________________________
Bank ___________________________________________________________
Address _________________________________________________________
Account No. _____________________________________________________
Is it in your name or in joint names? __________________________________
Do you have a savings account(s)? __________________________________________
Where is/are your savings account(s)? ________________________________
Bank ___________________________________________________________
Address _________________________________________________________
Account No. _____________________________________________________
Is it in your name or in joint names? __________________________________
Do you have a certificate of deposit? _________________________________________
Where is your certificate of deposit? __________________________________
Bank ___________________________________________________________
Address _________________________________________________________
Account No. _____________________________________________________
Is it in your name or in joint names? __________________________________
Bank books and canceled checked are kept ____________________________________
Do you have an IRA? _____________________________________________________
IRA account location ______________________________________________
Do you have a safe deposit box? ____________________________________________
Bank ___________________________________________________________
Address _________________________________________________________
Is it jointly held? __________________ Key is kept ______________________
U.S. SAVINGS BONDS
Do you have any U.S. savings bonds? _________________________________________
Where are they? __________________________________________________________
In whose names are they registered? __________________________________________
I have designated a co-owner or beneficiary, whose name is listed below:
Yes ______ Name ____________________________________________ No ______
Do you have a list of bonds, by serial number and denomination? ___________________
Location of this list ________________________________________________________
OTHER BONDS AND CORPORATE STOCKS
Do you own any other bonds or any preferred or common stocks?
Sole owner ____________________________ Joint owner ________________________
Where are they? __________________________________________________________
Broker __________________________________________________________________
Address _________________________________________________________________
________________________________________________________________________
List and records of purchases are kept _________________________________________
OTHER PERSONAL PROPERTY
In whose name is your motor vehicle(s) titled under? _____________________________
Vehicle and insurance policy are kept _________________________________________
Are household furnishings insured? ___________________________________________
Household furnishings insurance policy is kept __________________________________
Policies, inventory, and bills of sale are kept ____________________________________
CEMETERY PLOT
Do you own a cemetery plot? ________________________________________________
Where? _________________________________________________________________
Deed is kept _____________________________________________________________
IS SELF-EMPLOYED
Business name ___________________________________________________________
Address ________________________________________________________________
_______________________________________________________________________
Copies of business agreements, other documents are kept _________________________
For advice as to handling or disposition of the business, consult ____________________
Address ________________________________________________________________
_______________________________________________________________________
F NOT SELF-EMPLOYED
Employer ______________________________________________________________
Address _______________________________________________________________
______________________________________________________________________
Telephone _____________________________________________________________
In emergency, call ______________________________________________________
THER MATTERS
Personal creditors or debtors, if any ___________________________________________
Copies of notes, loan agreements, and receipts are kept
____________________________
Income tax records and supporting data are kept _________________________________
Credit card records are kept _________________________________________________
Tax advisor ______________________________________________________________
Address _________________________________________________________________
Names, ages and relationship of those who would inherit property under your will (heirs,
Devisees, and beneficiaries):
Name Age Relationship Address
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Are any of the above under legal disability or otherwise represented by personal representatives?
Name Legal Disability Represented by: Name and address
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Medical and Prescription Records
MEDICAL INFORMATION
My allergies and drug sensitivities: ___________________________________________
________________________________________________________________________
My blood type: ___________________________________________________________
Medical conditions I have ___________________________________________________
________________________________________________________________________
DOCTORS WHO ARE TREATING ME
Name ____________________ Specialty ____________________ Phone ___________________
Name ____________________ Specialty ____________________ Phone ___________________
Name ____________________ Specialty ____________________ Phone ___________________
Hospital ________________________________________________________________________________
Name ____________________ Emergency Phone Number _______________________________
Pharmacy _______________________________________________________________________________
Name ______________________________________Phone_______________________________
Dentist __________________________________________________________________________________
Name ______________________________________ Phone ______________________________
Prescription Information
Name of drug ___________________________
Date
Prescribed ______________________________
Doctor’s name ___________________________
Prescribed for what? ______________________
Color/shape/strength ______________________
Directions/cautions _______________________
_______________________________________
Prescription Information
Name of drug ___________________________
Date
Prescribed ______________________________
Doctor’s name ___________________________
Prescribed for what? ______________________
Color/shape/strength ______________________
Directions/cautions _______________________
_______________________________________
Prescription Information
Name of drug ___________________________
Date
Prescribed ______________________________
Doctor’s name ___________________________
Prescribed for what? ______________________
Color/shape/strength ______________________
Directions/cautions _______________________
_______________________________________
Prescription Information
Name of drug ___________________________
Date
Prescribed ______________________________
Doctor’s name ___________________________
Prescribed for what? ______________________
Color/shape/strength ______________________
Directions/cautions _______________________
_______________________________________
Prescription Information
Name of drug ___________________________
Date
Prescribed ______________________________
Doctor’s name ___________________________
Prescribed for what? ______________________
Color/shape/strength ______________________
Directions/cautions _______________________
_______________________________________
Prescription Information
Name of drug ___________________________
Date
Prescribed ______________________________
Doctor’s name ___________________________
Prescribed for what? ______________________
Color/shape/strength ______________________
Directions/cautions _______________________
_______________________________________
Prescription Information
Name of drug ___________________________
Date
Prescribed ______________________________
Doctor’s name ___________________________
Prescribed for what? ______________________
Color/shape/strength ______________________
Directions/cautions _______________________
_______________________________________
Prescription Information
Name of drug ___________________________
Date
Prescribed ______________________________
Doctor’s name ___________________________
Prescribed for what? ______________________
Color/shape/strength ______________________
Directions/cautions _______________________
_______________________________________
Prescription Information
Name of drug ___________________________
Date
Prescribed ______________________________
Doctor’s name ___________________________
Prescribed for what? ______________________
Color/shape/strength ______________________
Directions/cautions _______________________
_______________________________________
Prescription Information
Name of drug ___________________________
Date
Prescribed ______________________________
Doctor’s name ___________________________
Prescribed for what? ______________________
Color/shape/strength ______________________
Directions/cautions _______________________
_______________________________________
Prescription Information
Name of drug ___________________________
Date
Prescribed ______________________________
Doctor’s name ___________________________
Prescribed for what? ______________________
Color/shape/strength ______________________
Directions/cautions _______________________
_______________________________________
Prescription Information
Name of drug ___________________________
Date
Prescribed ______________________________
Doctor’s name ___________________________
Prescribed for what? ______________________
Color/shape/strength ______________________
Directions/cautions _______________________
_______________________________________