Dated personal information My Full Name Social Security Number Date of Birth Place of Birth Home Address City State Zipcode Home Phone Mobile Phone Email Address U.S. Citizen? Current Marital Status Florida Resident? Single Married Widowed Spouse s Full Name Date of Birth Resident Since Divorced Legally Separated Social Security Number Place of Birth Mobile Phone Email Address U.S. Citizen? Florida Resident? Do you have a Prenuptial or Postnuptial agreement? Children? Resident Since Date If yes, please list full names, address and phone for all children involved in your estate. 1. 2. 3. 4. 5. 6.
page 2 personal advisors Attorney Accountant Investment Advisor Bank/Trust Officer Insurance Agent Other military service I served in the From My serial number was My spouse served in the My spouse s serial number was To / / From / To /
page 3 medical records Physician #1 Physician #2 OF PRACTICE OF PRACTICE OF PRACTICE OF PRACTICE OF PRACTICE Physician #3 Dentist Other
page 4 advanced directives Please check the following Advanced Directives that you and/or your spouse currently have LIVING WILL stating my desires for health care in the event of my terminal illness. Date of my Living Will Date of my spouse s Living Will HEALTH CARE SURROGATE DIRECTIVE appointing a surrogate to make medical decisions in the event of my incapacity. My Health Care Surrogate is My Alternate Surrogate is Date of my Health Care Surrogate My spouse s Health Care Surrogate is My spouse s Alternate Surrogate is Date of my spouse s Health Care Surrogate DURABLE POWER OF ATTORNEY appointing an Attorney-in-Fact to handle my financial affairs in the event of my incapacity. My Attorney-in-Fact is My Alternate Attorney-in-Fact is Date of my Durable Power of Attorney My spouse s Attorney-in-Fact is My spouse s Alternate Attorney-in-Fact is Date of my spouse s Durable Power of Attorney
page 5 last will and testament I have a will dated The original is located at Personal Representative Alternate Representative Trustee Alternate Trustee Wills/Codicils drafted by My spouse has a will dated The original is located at Personal Representative Alternate Representative Trustee Alternate Trustee Wills/Codicils drafted by
page 6 trusts I have a Revocable Trust dated The original of my Trust is located at Trustee Alternate Trustee Trust drafted by My spouse has a Revocable Trust dated The original of my spouse s Trust is located at Trustee Alternate Trustee Trust drafted by
page 7 funeral and burial/cremation instructions My preferred funeral and burial/cremation instructions are My cemetery plot is # Section# In OF CEMETERY (COUNTY) The deed to my plot is located at COMPLETE or My cremation plans are as follow I have pre-paid funeral arrangements with Amount paid $ Complete address Phone I wish to donate organs to Address Phone My spouse s preferred funeral and burial/cremation instructions are My spouse s cemetery plot is # Section# The deed to my spouse s plot is located at or In OF CEMETERY (COUNTY) COMPLETE My spouse s cremation plans are as follow My spouse has pre-paid funeral arrangements with Amount paid $ Complete address Phone I wish to donate organs to Address Phone
life insurance I have the following life insurance policies Insurance Company Policy Number Cash Value Death Benefit Beneficiary(s) Insurance Company Policy Number Cash Value Death Benefit Beneficiary(s) Insurance Company Policy Number Cash Value Death Benefit Beneficiary(s) page 8