Last Day Planner_NEW_PIC_2018

ORRYFREE
RETIREMENT ®
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This Planner Belongs To:
Name:_________________________
Date__________________________
Retirement Specialist: ____________
2

An increasing challenge is keeping
family records current and centrally
located. At the heart of The
WorryFree Retirement ® Process is the
need to easily identify and locate such
records; especially at the death of a
loved one. After completing this
Planner, a copy should be given to a
trusted family member and/or your
trusted financial advisor.
We trust this planner will be of help
to you and your loved ones.
Sincerely,
Tony Walker, Creator
The WorryFree Retirement ®
A special thanks to Joe Zingone of
Cedar Knolls, NJ for designing the
content of this planner.
3

Table of Contents
Take Time Now to Plan 5
How to Make the Best Use of This Kit 6
Location of Records Checklist 7
Family Records and Information 13
Wills and Safe Deposit Boxes 14
Insurance and Annuities 15
Benefits Available Upon My/Spouse’s Death 18
Social Security Information 20
Sources of Immediate Cash 21
Trusts and Real Estate Information 22
Financial Assets 23
Business, Farm or Other Enterprise Information 24
Personal Effects 25
Funeral and Burial Preferences 27
Obituary Information 29
People to Notify 30
Additional Instructions and Information 33
Changes, Correction Updates 34
4

Take Time Now to Plan
Each member makes a valuable contribution to the family but when a family
member dies, how do the survivors cope?
The purpose of Survivor’s Guide: Take Time Now to Plan, is to motivate you
to make plans for an orderly transition. Eventually, someone will have to handle
your affairs without you. Please sit down and complete Survivor’s Guide:
Take Time Now to Plan. Preparation will ease the burden of your survivors.
We recommend that you give adequate consideration to matters such as:
What funeral arrangements would you prefer?
What will be the state of the family’s finances if you die? If your spouse/
partner dies?
Where would be the most practical place for the survivor(s) to live?
Specifically, who could be helpful to the survivor(s) in making decisions?
What benefits will the survivor(s) be eligible for?
What records are needed to apply for those benefits, and where are they located?
If you own a business, farm, or other enterprise, what should be done with
it ?
What arrangements should be made for the care of dependent children in
the event of simultaneous death of the parents?
Please take the time to plan now while it is just a chore, and not an additional
burden later to those you leave behind. The death of a loved one is excruciating
enough without the responsibilities of settling their affairs. Make the arrangements
and assemble the documents that will at least make the financial and legal
arrangements as simple as possible.
This publication provides a convenient place to list those arrangements and to
record where valuable documents are kept. You will undoubtedly want to talk
with an attorney, your life insurance agent, and other financial advisors to help
assemble your affairs. You will want to make sure that both you and your
spouse/partner have valid wills, that your life insurance program is adequate
for the financial needs of your family, and that federal estate taxes will be held
to a minimum.
Take the time to record your information here now. It is a caring way to help
your family through what will be one of the most trying periods of their lives.
5

How To Make The Best Use Of This Kit
This "Facts of Your Life" kit can help you accomplish two important tasks. First, it
helps you decrease the stress of record keeping in your daily life by providin a one-stop
resource for basic family information. Secondly, completing the elements will ease the
paperwork stress on your family in the event of a disability or death.
How successfully these tasks are accomplished depends largely on the completeness
and clarity with which the booklet is filled in. Complete the information as if this is the
only guide available to someone who will never be able to check with you directly on
any of the information.
1. Scan the whole booklet. You may find it easiest to go through the first time and
note the information that is readily available, then go back and fill in the missing
pieces.
2. If a section does not apply to you, indicate that it does not apply and go on to
the next section. Your family will know that you did not unintentionally leave
something blank.
3. Take the time to find all the information and fill out the forms completely. You
know where to find the answers, someone else who must use the information may
not.
4. Modify the pages if you need to, e.g. if you are unmarried but have someone
you would like to include, cross through "spouse" and replace it with a term that
describes their relationship to you, such as "lifetime partner" or "special friend".
5. Print or type legibly.
6. Keep the forms up-to-date. Make a date with yourself and your family to
change them the same time every year, e.g. when you file your taxes.
7. In filling in line-by-line elements keep these factors in mind:
Name - full name, spelled correctly Address - city, state, zip code
Phone - area code and phone number
Location of records - signed, dated and, if applicable, witnessed copies
8. If you store any of this information on computer note the computer location, file
location, type of software used, and name of the file. Make sure to keep a copy of
back-up disks in a safe place.
9. Photocopy any of the forms for additional family information.
10. Keep this kit in a safe and easily accessible location. Make your family aware
of that location.
6

Documents:
What to Keep Where to Store When to Shred
The financial services industry certainly produces a lot of paper! Here’s what you need to
keep and when you can trash it. Start by stacking all the paper in one big pile. Check your
drawers (home and work), filing cabinets, folders, boxes, glove compartments, even your
safe deposit box. Then separate the papers into these five groups:
1. Originals you rarely need
2. Originals you sometimes need.
3. Other Documents
4. Tax Documents
5. Investment Documents
1. Originals you
rarely need
Store in: Shred after: Give copies to:
Adoption papers Bank safety deposit box Never discard Executor, lawyer
Citizenship papers Bank safety deposit box Never discard Executor
Divorce decree Bank safety deposit box Never discard Lawyer
Lawsuits Bank safety deposit box Never discard Lawyer
Household
inventory
Photos of
possessions
Bank safety deposit box Never discard Insurance Agent
Bank safety deposit box Never discard Financial advisor
Military discharge Bank safety deposit box Never discard Never discard
Veteran’s papers Bank safety deposit box Never discard Never discard
7

2. Originals you
sometimes need
Store in: Shred after: Give copies to:
Birth certificate Fire and burglar resistant Never discard
NA
safe at home
Cemetery deed Fire and burglar resistant Never discard Heir
safe at home
Real Estate Deeds Fire and burglar resistant Ten years after NA
safe at home property is sold
Death certificates
Locked filing cabinet
Never discard Executor
Diplomas Fire and burglar resistant
safe at home
Guardianship Fire and burglar resistant
arrangements safe at home
Health records Fire and burglar resistant
safe at home
Immunization Fire and burglar resistant
records
safe at home
Marriage certificates
Fire and burglar resistant
safe at home
Medical directive Fire and burglar resistant
safe at home
Naturalization Fire and burglar resistant
Certification safe at home
Passports Fire and burglar resistant
safe at home
Powers of attorney Fire and burglar resistant
safe at home
Retirement plan Fire and burglar resistant
benefits
safe at home
Social Security Fire and burglar resistant
card
safe at home
Stock/bond Fire and burglar resistant
certificates safe at home
Vehicle titles Fire and burglar resistant
safe at home
Trusts Fire and burglar resistant
safe at home
Wills Fire and burglar resistant
safe at home
8
Never discard
Never discard
Never discard
Never discard
Never discard
New one signed
Never discard
It expires
New one signed
Never discard
Never discard
When sold
Vehicle is sold
New one signed
New one signed
NA
Executor, guardian
Doctor
Doctor
Executor
Doctor, heir
NA
NA
Doctor, heir
Financial advisor
NA
NA
NA
Executor, heir
Executor, heir

3. Other Documents Store in: Shred after: Give copies to:
College financial aid
Credit report
Document inventory
(this list)
Locked filing cabinet
Fire and burglar resistant
safe at home
Fire and burglar resistant
safe at home
Ten years after
loan is repaid
New one arrives
You create a
new list
NA
Financial advisor
Executor
Employee benefits Locked filing cabinet Change jobs NA
Employment contract
Financial statements
Insurance policies/
invoices
Letter of last instructions
Loan statements
Passwords
Property tax assessment
Receipts (items under
warranty)
Receipts (expensive
items)
Safe deposit box inventory
Social Security
statement
Transcripts
Fire and burglar resistant
safe at home
Fire and burglar resistant
safe at home
Locked filing cabinet
Fire and burglar resistant
safe at home
Locked filing cabinet
Fire and burglar resistant
safe at home
Change jobs
New ones drafted
A year after
replacing policy
After writing a
new one
Ten years after
loan is repaid
Change
password
NA
NA
Financial advisor
Executor
NA
NA
Locked filing cabinet New one arrives NA
Locked filing cabinet Warranty expires NA
Fire and burglar resistant
safe at home
Fire and burglar resistant
safe at home
Item sold or
donated
Updated
NA
Executor
Locked filing cabinet New one arrives Financial advisor
Locked filing cabinet
You complete
another course
Vehicle registration Locked filing cabinet New one arrives NA
Vehicle repairs Locked filing cabinet Vehicle is sold NA
Warranties* Locked filing cabinet Dispose of item NA
NA
9

improvement*
Tax return/supporting
documents
Form 8606
Locked filing cabinet
Locked filing cabinet
4. Tax Documents Store in: Shred after: Give copies to:
Bank statements Locked filing cabinet Seven years NA
Canceled checks Locked filing cabinet Seven years NA
Credit card
statements
Locked filing cabinet Seven years NA
Home purchase/
Locked filing cabinet
Seven years af-
NA
ter home is sold
Seven years
after filing date
Seven years
after IRA is
liquidated
*deeds, surveys, title policies, blueprints, loan papers, receipts, etc.
5. Investment
Documents
Store in: Shred after: Give copies to:
Annuity contracts Locked filing cabinet Annuity paid out Financial advisor
Loan agreements Locked filing cabinet
Ten years after
loan is repaid
NA
Pension plan documents
Real Estate purchase/improvements
Investment account
statements
Keeping these records stored safely, where you and others can find them, can save you
time and greatly increases the likelihood that they will not get lost.
If you need help collecting and understanding these documents, contact your financial
advisor.
NA
NA
Locked filing cabinet Never discard Financial advisor
Locked filing cabinet
Locked filing cabinet
Seven years after
property is
sold
Seven years
after last investment
held in
account is sold
NA
NA
10

Location of Important Papers
Adoption certificates_______________________________________________
Annuities________________________________________________________
Bank book, check book_____________________________________________
Bank monthly statements___________________________________________
Birth certificates__________________________________________________
Bonds__________________________________________________________
Business agreements or contracts____________________________________
Cancelled checks_________________________________________________
Certificates of deposit______________________________________________
Credit cards_____________________________________________________
Death certificates_________________________________________________
Divorce Documentation____________________________________________
Drivers Licenses__________________________________________________
Federal and State Income Tax Returns________________________________
Fraternal and trade societies with benefits provided______________________
Household financial records_________________________________________
Insurance policies_________________________________________________
List of people to whom you owe money, and terms_______________________
List of people who owe money to you, with notes________________________
Location of safes and combinations___________________________________
Marriage certificates_______________________________________________
Medical records__________________________________________________
Military service records, including serial number________________________
Mutual funds_____________________________________________________
Medical records__________________________________________________
Notes Payables/ Receivables_______________________________________
Other investment statements________________________________________
11

Location of Important Papers (continued)
Passports_______________________________________________________
Pension, profit sharing, or other retirement, or death benefits_______________
Real estate deeds, copy of mortgages_________________________________
Retirement Asset Will ______________________________________________
Social Security Cards______________________________________________
Software passwords, codes_________________________________________
Stock, Bonds and Securities certificates_______________________________
V.A. claim number_________________________________________________
Vehicle registrations and title________________________________________
Veteran’s Discharge certificate_______________________________________
W-2 / Earnings Records____________________________________________
Other___________________________________________________________
_______________________________________________________________
_______________________________________________________________
12

Family Records and Information
About the Family
My Name:______________________________________________________________
Place and Date of Birth:___________________________________________________
Spouse’s Name:__________________________________________________________
Place and Date of Birth:___________________________________________________
Children (full name, place and date of birth):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Other Family (full name, place and date of birth):
__________________________________________________________________
Family Records Location
Medical Records_________________________________________________________
Marriage Certificates______________________________________________________
Other Important Family Records____________________________________________
_______________________________________________________________________
_______________________________________________________________________
* For simplicity, the term “spouse” will be used throughout the remainder of the text.
13

Wills/Trusts and Safe Deposit Boxes
Wills and Trusts (Circle One or Both)
I have a will / trust. (Circle One or Both)
I do not have a will/trust. (NOTE: if you checked this box, you have an important
duty to perform, now.)
Original and copies of my will/trust are located at:_____________________________
_______________________________________________________________________
Executor’s name, address, and telephone number_______________________________
_______________________________________________________________________
Name of Attorney, address, and telephone number______________________________
_______________________________________________________________________
Safe deposit boxes (Circle one)
I do not have a safety deposit box
It is held in my name only
It is held jointly with__________________________________________________
Box number_____________________________________________________________
Name and location of bank_________________________________________________
Location(s) of keys_______________________________________________________
14

Insurance and Annuities
Life Insurance (Yes No)
I have the following life & Life/long-term care insurance policies:
Insurance Company Policy # Face Value Beneficiary
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
* If any policies listed are survivorships (last-to-die) plans, it is also important to notify
the insurer.
Other Family Members:
Insurance Company Policy # Face Value Beneficiary
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Government Life Insurance (Yes No)
I served in the (branch of service)______________________________from ________
to______________and received the following type of discharge ___________________
_______________________________________________________________________
My serial number was____________________________________________________
The status of my government life insurance is as follows (expired or still in force; face
amount:________________________________________________________________
_______________________________________________________________________
_______
The policy is located at __________________________________________________
_____________________________________________________________________________
_____________________________________________________________
15

Insurance and Annuities (continued)
Other Government sources
My Family will be eligible for those benefits, which are checked and described below:
Railroad Retirement
Civil Service
Active military of veterans’ service-connected death
Veterans’ non-service-connected death
Benefits because of my employment by state of local government_________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
My V.A. Claim number is:_________________________________________________
Records and documents needed to apply for benefits are located at__________________
_______________________________________________________________________
Membership organizations
Because of my membership in various organizations (union, trade associations, fraternal
benefit society, etc.), my survivors may be eligible for certain benefits. The organizations
and benefits are as follows:
Organization Type of Benefit
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
The papers needed to apply for such benefits are located at
_______________________________________________________________________
_______________________________________________________________________
16

Insurance and Annuities (continued)
Health Insurance
Our health insurance policies (hospitalization, disability income, accident, long-term
care, etc Medicare Supplement) are as follows:
Insured Insurance Co. Policy No. Type of Insurance Phone
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Annuities
We have the following annuities:
Insurance Co. Policy No. Annuitant Beneficiary
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Property/casualty insurance
We have the following typed of insurance (homeowners, automobile, personal liability,
business coverages, fire, vehicle, and disability etc.):
Insurance Co. Policy No. Type of Insurance Phone
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Policies for all insurance converges and annuities are located______________________
17

Benefits Available Upon My Death
Available Death Benefits, Present Employer
My employer is (name, address, telephone number):__________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
My family may be eligible for the following benefits from my employer upon my death.
(Yes No) if yes check all that apply:
Group life insurance
Deferred compensation
Group health insurance (death benefit)
Credit union deposits
COBRA continuation coverage
Pension (survivors benefits)
Profit-sharing plan (survivors benefits)
Unpaid salary
Other
If I am killed on the job, additional benefits may be payable to my family from:
Workmen’s compensation Accident travel insurance, common carrier insurance, tickets purchased
by credit card Other
Past Employer(s) (Yes
No)
Because of my previous employment there, I have a vested interest in the pension plan or other
benefits at:___________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Papers needed to apply for benefits are located at:____________________________________
____________________________________________________________________________
____________________________________________________________________________
18

Benefits Available Upon My Spouse’s Death
Available Death Benefits, Present Employer
My employer is (name, address, telephone number):__________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
My family may be eligible for the following benefits from my employer upon my death.
(Yes No) if yes check all that apply:
Group life insurance
Deferred compensation
Group health insurance (death benefit)
Credit union deposits
COBRA continuation coverage
Pension (survivors benefits)
Profit-sharing plan (survivors benefits)
Unpaid salary
Other
If I am killed on the job, additional benefits may be payable to my family from:
Workmen’s compensation Accident travel insurance, common carrier insurance, tickets purchased
by credit card Other
Past Employer(s) (Yes
No)
Because of my previous employment there, I have a vested interest in the pension plan or other
benefits at:___________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Papers needed to apply for benefits are located at:____________________________________
____________________________________________________________________________
____________________________________________________________________________
19

Social Security
The Social Security Administration offers a variety of benefits. Call 1-800-772-1213 for help in
calculating the dollar amounts below, and for complete details on all Social Security Benefits.
A lump sum burial benefit of $255 may be payable to my spouse or children.
Social Security may provide my spouse, ex-spouse, and/or children a monthly benefit of
$ ________________
My Social Security number:_____________________________________________________
Spouses’ Social Security number:________________________________________________
Children’s Social Security numbers:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
To receive benefits you will need the following information:
• A certified copy of the death certificate
• The deceased’s Social Security number
• Information on the deceased’s employer, and approximate earnings for the past two years,
such as tax returns, or W-2’s
• Your marriage certificate
Social Security numbers and birth certificates for you and your dependent children
NOTE: Order at least 15 death certificates. A separate certified death certificate
will be needed for each insurance policy, and each asset, (i.e., real estate, stocks,
bonds, mutual funds, bank accounts, etc.) The funeral director can order them
for you.
20

Sources of Immediate Cash / Care of Dependent Children
Sources of Immediate Cash
During the period immediately following my death, the best sources for my family to obtain cash
for immediate needs are as follows:___________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
During the period immediately following my spouse’s death, the best sources for me to obtain
cash to meet the additional expenses are as follows:__________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Care of Dependent Children
In the event my spouse and I both die while our children are young, the following arrangements
have been made on their behalf (give name, relationship, address, and telephone number of
guardian, and describe trust arrangements, if any):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Or, my will contains the following guardianship designation and trust arrangement:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Or, no official arrangements have been made to date, but my spouse and I would hope that the
following arrangements could be made:____________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
21

Trusts and Real Estate Information
Trust(s) that I Have Set Up:________________________________________________
____________________________________________________________________________
The bank, trust company, or other fiduciary:________________________________________
Trust officer:_________________________________________________________________
Telephone number:____________________________________________________________
The trust is:
Funded
Unfunded
Trust(s) My Spouse Has Set Up:_____________________________________
____________________________________________________________________________
The bank, trust company, or other fiduciary:________________________________________
Trust officer_________________________________________________________________
Telephone number:____________________________________________________________
The trust is:
Funded
Unfunded
Real Estate Owned
Home address:________________________________________________________________
It is owned:
Jointly by____________________________________________________________________
Singly by____________________________________________________________________
Mortgagor:___________________________________________________________________
Telephone number_____________________________________________________________
Location of mortgage or deed:____________________________________________________
We have a second home at:______________________________________________________
It is owned:
Jointly by___________________________________________________________________
Singly by___________________________________________________________________
Mortgagor:__________________________________________________________________
Telephone number____________________________________________________________
Other real estate owned (excluding business, farm, or other enterprise):
____________________________________________________________________________
22

Financial Assets
Bank Accounts (Including Savings & Loan Associations, Credit Union)
Checking, savings
Certificates of Deposit Account # Joint/Ind. Owner Name & Location
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_________________________________________________________________________
Location of passbooks, checkbooks, cancelled checks, and statements____________________
_____________________________________________________________________________
___________________________________________________________________________
Stocks, Bonds, and Securities Portfolio
Stocks, bonds, securities________________________________________________________
Records located_______________________________________________________________
Mutual Fund Companies________________________________________________________
Records located_______________________________________________________________
Money Market account(s)_______________________________________________________
Records located_______________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Additional Financial Information
Major debts (other than first mortgages and revolving charge accounts):__________________
_____________________________________________________________________________
___________________________________________________________________________
Money owed to us:_____________________________________________________________
____________________________________________________________________________
Location of notes payable and receivable:___________________________________________
____________________________________________________________________________
Other Information:_____________________________________________________________
____________________________________________________________________________
23

Business, Farm, or Other Enterprise Information
Name of business________________________________________________________
Kind of business_________________________________________________________
Location_______________________________________________________________
Percentage of ownership (%)_______________________________________________
Form of business (sole proprietorship, partnership, corporation)___________________
_______________________________________________________________________
_______________________________________________________________________
Other owners (if any):____________________________________________________
_______________________________________________________________________
Is the business subject to a buy/sell agreement?_______________________________
_______________________________________________________________________
Information on any other business interests or farms owned_______________________
_______________________________________________________________________
_______________________________________________________________________
Arrangements that have been made (or should be made after my death) in continuing or
disposing of each business interest _________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Location of business books, records and pertinent papers_________________________
_______________________________________________________________________
Additional information____________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Person or persons who could offer sound advice in carrying on the business, or operating
the farm - or in disposing of the business or farm (names, addresses, and telephone
numbers)
_______________________________________________________________________
_______________________________________________________________________
24

Personal Letter of Direction
Dear Family and Friends:
As you know, maintaining harmony in the family has always been a priority with me.
One way to continue this objective is to be sure there are no misunderstandings as to
certain personal property items that are to be distributed at my death. I know from painful
firsthand experience how a devastating family dispute can develop because these issues
are not addressed at the appropriate time. I have given a great deal of thought as to
how this goal might be accomplished. Therefore, on the following pages you will find a
list of specific items to be distributed to specific individuals.
I recognize that some of the items do not have great monetary value. However, I do
know that they are of great sentimental value to me, and perhaps will be to you as well. I
hope you will find as much joy in receiving these items as I have had in gifting them to
you.
I apologize if any of you feels slighted because I directed an item to someone else that
you thought was intended for you. Please be assured that I have done my best to be sure
that everyone is treated fairly. If I fall short in that desire it is because of my own shortcomings,
and is not borne out of a desire to hurt anyone’s feelings.
Thank you for your love and support
My Personal Effects
At the discretion of my executor or next of kin, I suggest that the distribution of my personal
effects (not covered in my will) be as follows (what it is and who is to receive it):
Item(s)
Person to receive
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
25

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Spouse’s Personal Effects (if different)
At the discretion of my executor or next of kin, I suggest that the distribution of my personal
effects (not covered in my will) be as follows (what it is and who is to receive it):
Item(s)
Person to receive
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
26

Body or Organs to be Donated:
Funeral and Burial Preferences
(Husband)
Yes (indicate specific organs NOT to be donated, if any)
__________________________
No (see Health Care Durable Power of Attorney, or Health Care Directive)
Preferred mortuary:_______________________________________________________
City: __________________________________________________________________
State:__________________________________________________________________
Place of Service:_________________________________________________________
Church:________________________________________________________________
Mortuary Chapel:________________________________________________________
Church or Denomination:__________________________________________________
Person to be in Charge of Final Arrangements:_____________________________
(see Health Care Durable Power of Attorney, or Health Care Directive)
Relationship:____________________________________________________________
Telephone:______________________________________________________________
Description of Services Desired:___________________________________________
_______________________________________________________________________
_______________________________________________________________________
Special Readings or Music:_______________________________________________
Service to be Conducted by:_______________________________________________
Relationship:____________________________________________________________
Telephone:______________________________________________________________
Internment Requests
I prefer:
Earth burial
Cremation
Mausoleum
Name of Cemetery:
City:___________________________________________________________________
State:__________________________________________________________________
( ) I have reserved facilities (attach deed, and/or, other paperwork)
( ) I have not reserved facilities
27

Body or Organs to be Donated:
Funeral and Burial Preferences
(Wife)
Yes (indicate specific organs NOT to be donated, if any)________________________
No (see Health Care Durable Power of Attorney, or Health Care Directive)
Preferred mortuary:_______________________________________________________
City: __________________________________________________________________
State:__________________________________________________________________
Place of Service:_________________________________________________________
Church:________________________________________________________________
Mortuary Chapel:________________________________________________________
Church or Denomination:__________________________________________________
Person to be in Charge of Final Arrangements:_____________________________
(see Health Care Durable Power of Attorney, or Health Care Directive)
Relationship:____________________________________________________________
Telephone:______________________________________________________________
Description of Services Desired:___________________________________________
_______________________________________________________________________
_______________________________________________________________________
Special Readings or Music:_______________________________________________
Service to be Conducted by:_______________________________________________
Relationship:____________________________________________________________
Telephone:______________________________________________________________
Internment Requests
I prefer: Earth burial Cremation Mausoleum
Name of Cemetery:
City:___________________________________________________________________
State:__________________________________________________________________
( ) I have reserved facilities (attach deed, and/or, other paperwork)
( ) I have not reserved facilities
28

Obituary Information
This biographical information will be of help in preparing an obituary news story about
me____________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
My obituary should be sent to the following newspapers:_________________________
_______________________________________________________________________
_______________________________________________________________________
This biographical information will be of help in preparing an obituary news story about
my
spouse:_________________________________________________________________
_____
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
My spouse’s obituary should be sent to the following newspapers:__________________
_______________________________________________________________________
_______________________________________________________________________
29

People to Contact
(Husband)
Name:_________________________________________________________________
Relationship:____________________________________________________________
Address:________________________________________________________________
Telephone: _____________________________________________________________
Name:_________________________________________________________________
Relationship:___________________________________________________________
Address:_ ________________________________________________________ _____
Telephone:______________________________________________________________
Name:_________________________________________________________________
Relationship:____________________________________________________________
Address:________________________________________________________________
Telephone:______________________________________________________________
Name:_________________________________________________________________
Relationship:____________________________________________________________
Address:________________________________________________________________
Telephone______________________________________________________________
30

_______________________________________________________________________
Name:_________________________________________________________________
Relationship:____________________________________________________________
Address:________________________________________________________________
Telephone:______________________________________________________________
Name:_________________________________________________________________
Relationship:____________________________________________________________
Address:________________________________________________________________
Telephone:______________________________________________________________
People to Contact
(Wife)
Name:_________________________________________________________________
Relationship:____________________________________________________________
Address:________________________________________________________________
Telephone:______________________________________________________________
Name:_________________________________________________________________
Relationship:____________________________________________________________
Address:_______________________________________________________________
31

Telephone:______________________________________________________________
Name:________________________________________________________________
Relationship:____________________________________________________________
Address:________________________________________________________________
Telephone:______________________________________________________________
Name:_________________________________________________________________
Relationship:____________________________________________________________
Address:________________________________________________________________
Telephone:______________________________________________________________
Name:_______________________________________________________________
Relationship:___________________________________________________________
Address:________________________________________________________________
Telephone:______________________________________________________________
Name:_________________________________________________________________
Relationship:____________________________________________________________
Address:________________________________________________________________
32

Additional Instructions and Information
Additional instructions or information for survivors that has not been covered previously:____
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Date completed and/or updated:__________________________________________________
My Signature_________________________________________________________________
My Spouse’s Signature_________________________________________________________
Witness______________________________________________________________________
Address______________________________________________________________________
Witness______________________________________________________________________
Address______________________________________________________________________
CERTIFICATE OF ACKNOWLEDGEMENT OF NOTARY PUBLIC
State of ____________, County of:_________________________________________
On _______________ before me, __________________________________________
(Name/Title, i.e., “Jane Doe, Notary Public”)
personally appeared ______________________________________________________
personally known to me (or proved to me on the basis of satisfactory evidence) to be the
person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to
me that he/she/they executed the same in his/her/their authorized capacity(ies), and that
by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the instrument.
WITNESS my hand and official seal.
______________________________
(Signature) (Notary Seal)
33

Any Changes, Corrections, or Updates
Time has a way of changing things. Example bank names change,
people move etc. Use this page to keep your booklet current. Reference
page and item put new information here then place a line through old
information and reference Also date when change was completed.
34

Any Changes, Corrections, or Updates Continued
Use this space for information about your home: water shutoffs, keys
for shed, combination locks. Hidden electrical boxes. Shut off switches
etc.
35

©2006, TONY WALKER. ALL RIGHTS RESERVED
www.TonyWalkerFinancial.com
1-877-499-WALK