The Estate Planning Record Keeper

General Information

Last Updated:____________

Copies given to:______________________________________________________________

1. Information about yourself

Name:______________________________________________

Address:____________________________________________

Telephone:__________________________________________

Occupation:_________________________________________

Citizenship:__________________________________________

Social Security Number:________________________________

Date of Birth:_________________________________________

2. Information about your family

Mother’s name/address/phone (day/eve):___________________________________________

Father’s name/address/phone (day/eve):____________________________________________

Brother/Sister’s name/address/phone (day/eve):______________________________________

Son/Daughter’s name/address/phone (day/eve):______________________________________

Other relative’s name/address/phone (day/eve):______________________________________

Former/Separated spouse’s name/address/phone:_____________________________________
Date and location of divorce/separation:____________________________________________
Location of divorce/separation documents:__________________________________________

3. Other important contacts

Employer’s name/address/phone:__________________________________________________

Key work contact: name/phone:___________________________________________________

Family doctor’s name/address/phone:_______________________________________________

Your Insurance Policies

1. Life Insurance

Type of policy:_______________________________________

Expiration date:______________________________________

Policy number:_______________________________________

Company’s name/address/phone:________________________

Face value:_________________________________________

Cash value:_________________________________________

Beneficiary(ies):______________________________________

Agent’s name/address/phone:___________________________

Location of policy documents:___________________________

2. Health Insurance

Type of policy:________________________________________

Expiration date:_______________________________________

Company’s name/address/phone:_________________________

Policy number:________________________________________

Agent’s name/address/phone:____________________________

Location of policy documents:____________________________

3. Disability Insurance

Type of policy:________________________________________

Expiration date:_______________________________________

Company’s name/address/phone:_________________________

Policy number:________________________________________

Agent’s name/address/phone:____________________________

Location of policy documents:____________________________

4. Long Term Care Insurance

Type of policy:________________________________________

Expiration date:_______________________________________

Company’s name/address/phone:_________________________

Policy number:________________________________________

Agent’s name/address/phone:____________________________

Location of policy documents:____________________________

5. "MediGap" Insurance

Type of policy:_______________________________________

Expiration date:______________________________________

Company’s name/address/phone:________________________

Policy number:_______________________________________

Agent’s name/address/phone:___________________________

Location of policy documents:___________________________

6. Excess Personal Liability ("Umbrella") Insurance

Type of policy:________________________________________

Expiration date:_______________________________________

Company’s name/address/phone:_________________________

Policy number:________________________________________

Agent’s name/address/phone:____________________________

Location of policy documents:____________________________

7. Homeowners’ or Rental Insurance

Type of policy:________________________________________

Expiration date:_______________________________________

Company’s name/address/phone:_________________________

Policy number:________________________________________

Agent’s name/address/phone:____________________________

Location of policy documents:____________________________

8. Auto Insurance

Type of policy:________________________________________

Expiration date:_______________________________________

Company’s name/address/phone:_________________________

Policy number:________________________________________

Agent’s name/address/phone:____________________________

Location of policy documents:____________________________

9. Boat Insurance

Type of policy:_________________________________________

Expiration date:________________________________________

Company’s name/address/phone:__________________________

Policy number:_________________________________________

Agent’s name/address/phone:_____________________________

Location of policy documents:_____________________________

Your Assets

1. Cash

Value:______________________________________________

Location:____________________________________________

2. Savings Account

Account number:_____________________________________

Location of passbook or statements:______________________

Financial institution name/address/phone:__________________

3. Checking Account

Account number:_____________________________________

Location of checks and other documents:__________________

Financial institution name/address/phone:____________________________________________

4. Term Account: Certificates of Deposits, etc.

Identifying number and maturity date:_____________________

Location of documents:_________________________________

Financial institution name/address/phone:____________________________________________

5. Other (gold, silver, travelers or cashier checks, etc.)

Description:__________________________________________

Value:_______________________________________________

Location:_____________________________________________

6. Pension and Profit-sharing Plan

Company and account number:___________________________

Employer’s name/address/phone:___________________________________________________

Beneficiary(ies):_______________________________________

Location of documents:_________________________________

7. Keogh Plan and/or Individual Retirement Account (IRA)

Financial institution name/address/phone:____________________________________________

Account number:______________________________________

Beneficiary(ies):_______________________________________

Location of documents:_________________________________

8. Securities

Broker’s name/address/phone:_____________________________________________________

Account Number:_____________________________________

9. Stocks

Company, number of shares, certificate number, location of documents:

___________________________________________________

10. Bonds

Issuer, face value, certificate number, maturity, location of documents:

___________________________________________________

11. Mutual Funds

Company, number of shares, account number:

___________________________________________________

12. Other Financial Instruments

Description, location:__________________________________

13. Business Interests

Description (include ownership share if appropriate):__________________

Type of organization (partnership, corporation, etc.):__________________

Name/address/phone of other partners, owners:________________________________________

Location of financial records, etc.:_________________________

14. Notes Receivable (people/organizations owing you money)

Description:__________________________________________

Debtor’ name/address/phone:______________________________________________________

Amount of debt:_______________________________________

Terms:______________________________________________

Location of lending documents:___________________________

15. Annuity(ies)

Account number:_______________________________________

Company:____________________________________________

Payments’ scheduled start date:___________________________

Payments’ scheduled duration:____________________________

Payments’ scheduled amount:_____________________________

Beneficiary(ies):________________________________________

Agent’s name/address/phone:______________________________________________________

16. Real Estate

Location of property:___________________________

Title owned by:________________________________________

Name/address where taxes due:__________________________

17. Automobile

Make, type, year, vehicle identification number:__________________

Location of title:_______________________________________

18. Boat

Make, type, year, registration number:_________________________

Location of title:_______________________________________

19. Other Valuable Personal Property

Description:__________________________________________

Location:____________________________________________

Estimated value:______________________________________

Location of any associated documents:____________________

Your Debts

1. Credit Cards

Company, account number, name on card:________________________

2. Real Estate Loans

Description of property:__________________________________

First mortgage held by:__________________________________

Amount of first mortgage:_________________________________

Location of first mortgage documents:_______________________

Second mortgage held by:________________________________

Amount of second mortgage:_________________________________

Location of second mortgage documents:_______________________

3. Automobile Loan

Creditor’s name/address/phone:____________________________________________________

Co-signer’s name/address/phone (if any):____________________________________________

Amount of debt:_________________________________________

Terms:________________________________________________

Location of lending documents:_____________________________

4. Boat Loan

Creditor’s name/address/phone:____________________________________________________

Co-signer’s name/address/phone (if any):_____________________________________________

Amount of debt:_________________________________________

Terms:________________________________________________

Location of lending documents:_____________________________

5. Student Loan

Creditor’s name/address/phone:____________________________________________________

Co-signer’s name/address/phone (if any):____________________________________________

Amount of debt:_______________________________________

Terms:______________________________________________

Location of lending documents:___________________________

6. Other major creditors (those to whom you owe money)

Description:___________________________________________

Creditor’s name/address/phone:____________________________________________________

Co-signer’s name/address/phone (if any):_____________________________________________

Amount of debt:________________________________________

Terms:_______________________________________________

Location of lending documents:____________________________

7. Memberships and/or other regular obligations:

Description:___________________________________________

Amount due and frequency:_______________________________

Location of documents:__________________________________

Creditor’s name/address/phone:____________________________________________________

Documents

1. Safe Deposit Box

Box registered in the name of:____________________________

Bank’s name/address/phone:_____________________________

Location of key:________________________________________

Box contents:_________________________________________

2. Tax Returns

Location of returns:_____________________________________

Accountant’s name/address/phone:__________________________________________________

3. Will

Location of original:_____________________________________

Location of copy(ies):____________________________________

Attorney’s name/address/phone:____________________________________________________

Executor’s or Personal Representativeâ€™s name/address/phone:____________________________

Children’s guardian’s name/address/phone:___________________________________________

4. Trust Agreement

Location of original:_____________________________________

Location of copy(ies):____________________________________

Trust Officer or Trusteeâ€™s name/address/phone:_____________________________________________________________

5. Living Will

Location of original:_____________________________________

Location of copy(ies):___________________________________

6. Durable Power of Attorney

Location of original:_____________________________________

Location of copy(ies):___________________________________

7. Miscellaneous Documents

Birth certificate (location):_________________________________

Adoption documents (location):_____________________________

Baptismal certificate (location):_____________________________

School transcripts (location):_______________________________

Military service records (location):___________________________

Marriage certificate (location):______________________________

Passport (number and location):____________________________

Cemetery deed (location):_________________________________

Other Important Information

______________________________________________________________

Barney & McKenna PC Nevada Office:

Jeffery J. McKenna 590 West Mesquite Blvd., Suite 201

43 South 100 East, Suite 300, PO Box 2710 PO Box 3250

St. George, Utah 84770 Mesquite, Nevada 89024

(435) 628-1711 (702) 346-1615

The Estate Planning Record Keeper

Links

ATTORNEYS

Practice Areas