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This form can be used to record information useful to your Personal Representative or Executor or spouse after your death or disability.

Date:

My full name at present:

My full name at birth:

My place of birth:

My date of birth:

Certified copy of my birth certificate or adoption certificate is located at:

My Social Security Number:

My present address:

My Professional advisors:

Name Address Telephone

Lawyer:

Accountant:

Dentist:

Physician(s):

Insurance agent(s):

Location of my Last Will and Testament and/or Living Trust and/or power of attorney:

My Last Will and/or Living Trust was signed on:

Location of my Living Will declaring my intention with regard to sustaining bodily functions through respiratory equipment, etc., in case of terminal illness:

 Year I became a resident of Florida:

My usual occupation:

My date of retirement:

U. S. citizen By: Birth Naturalization

Military veteran: Yes No

Branch of service:

Dates of service:

Serial Number:

Final rank:

Marital status: _______ Never married ______Married ________ Divorced _______Widowed

Spouse's name:

Date of marriage:

Name(s) of prior spouse(s):

Date(s) of divorce or death of spouse:

My Child(ren):

Name Address Date birth/death Married

My Grandchildren:

Name Address Date birth/death Married

My Parents:

Name Address Date of birth/death

My Brother(s) and sister(s):

Name Address Date birth/death Married

My Grandparents:

Name Address Date of birth/death

My Nephews/Nieces:

Name Address Date birth/death Married

My Educational background:

Name Location Dates Degrees Elementary:

Junior High School(s):

High School(s):

Vocational School(s):

College(s) and Graduate School(s):

My Employment:

Employer(s) Location Position Dates Type of Work

Organizations:

Residences: Address Dates

Religious preferences and memberships:

Funeral or memorial arrangements:

Name Address Telephone

I have a cemetery lot/crypt at:

I have made arrangements for donation of body parts with: (Note: Florida law requires that certain arrangements be made in order for this to be valid.)

Florida Driver's License No.: Expires:

Passport No.: Expires:

Florida Voter Identification No.:

Monthly income:

Amount Source

Salary:

Interest:

Rental income:

Dividends:

Social Security:

Pension:

Annuity:

Other:

Veteran's benefits: Claim No.:

Monthly bills and expenses: Amount To

Credit cards:

Company Address Card Number

Major loans, mortgages and debts I owe:

Insurance

Life insurance companies:

Agent and address:

Policy Nos.: Face Amount:

Beneficiary:

Type of life insurance:

Medical insurance company:

Agent and address: Policy No.:

Homeowner's and casualty insurance company:

Agent and address: Policy No.:

Automobile insurance:

Agent and address: Policy No.:

Banks and savings accounts:

Institution Account No. Type of Account Co-owner

Safe deposit box(es):

Institution Box No.

Stocks and bonds:

Broker:

Account No.:

Branch:

Telephone No.:

Securities: Issuer No.shares Date purchased Cost Value

Real estate:

Address Legal Description Co-owner(s) Market Value

Business(es):

Address Legal Description Co-owner(s) Market Value

I have a possible claim to sue:

Address:

Reason:

Amount:

I have a lawsuit pending against:

Reason:

My Attorney:

I have an uncollected judgment against:

Address:

My Attorney:

I am the beneficiary of a trust:

Description:

I expect to receive an inheritance from: