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Personal Information _update 13009_ Powered By Docstoc
					Personal Information (update 1/30/09) Date: _____________
FULL LEGAL NAME _______________________________________________ ADDRESS ________________________________________________________ PHONES: HOME______________________ CELL______________________ MONTANA RESIDENT SINCE _______________________________________________ DATE OF BIRTH: MONTH______________ DAY ___________ YEAR _____________ BIRTH PLACE (CITY, COUNTY, STATE, ZIP CODE) ____________________________________________________________________________ OCCUPATION (PRESENT OR FORMER)_______________________________________ MARITAL STATUS: MARRIED ____ SINGLE ____ WIDOWED (date) _____________ DIVORCED (date) _____________________ I AM A CITIZEN OF _________________________________________________________ NAME OF SPOUSE/PARTNER (IF SPOUSE NOT RETIRED, PHONE NUMBER AT PLACE OF WORK) ____________________________________________________________________________ NAME OF FATHER, PLACE OF BIRTH, YEAR _________________________________ _____________________________________________________________________________ MOTHER’S MAIDEN NAME, PLACE OF BIRTH, YEAR _________________________ _____________________________________________________________________________

IF MARRIED:
SPOUSE’S FULL LEGAL NAME _______________________________________________ DATE OF BIRTH _______________SOCIAL SECURITY NUMBER__________________ CITIZEN OF _________________________________________________________________

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CHILDREN: NAME__________________________________ DATE OF BIRTH ____________________ ADDRESS ___________________________________________PHONE _________________

NAME__________________________________ DATE OF BIRTH ____________________ ADDRESS ___________________________________________PHONE _________________

NAME__________________________________ DATE OF BIRTH ____________________ ADDRESS ___________________________________________PHONE _________________

NAME__________________________________ DATE OF BIRTH ____________________ ADDRESS ___________________________________________PHONE _________________

NAME__________________________________ DATE OF BIRTH ____________________ ADDRESS ___________________________________________PHONE _________________ CUSTODIANS FOR MY CHILDREN (IN THE EVENT BOTH PARENTS/GUARDIANS HAVE
DIED)

NAME________________________________________PHONE________________________ ADDRESS____________________________________________________________________ _____________________________________________________________________________

NAME(S) OF ANYONE I RECOMMEND TO ASSIST WITH FINANCIAL AND/OR BUSINESS MATTERS: ______________________________________________________________________________ ______________________________________________________________________________

__________________________________________________________

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Benefit Information
SOCIAL SECURITY NUMBER _________________________________________________ MILITARY SERVICE ________________________________________________________ BRANCH, RANK, DATE OF ENLISTMENT ______________________________________ ______________________________________________________________________________ DATE OF DISCHARGE _______________________SERIAL NO______________________

UNION MEMBERSHIPS/BENEFITS ____________________________________________ _____________________________________________________________________________

Relatives and Friends to Notify Immediately
NAME AND RELATIONSHIP, CITY, STATE, PHONE NUMBER

_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________

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Advisors/Others to Be Contacted
ATTORNEY ___________________________ FIRM NAME_________________________ ADDRESS___________________________________________________________________ PHONE ____________________________ E-MAIL ________________________________

ACCOUNTANT __________________________ FIRM NAME_______________________ ADDRESS___________________________________________________________________ PHONE ____________________________ CONTACT PERSON_______________________

BANK ______________________________________________________________________ ADDRESS __________________________________________________________________ PHONE _____________________________ CONTACT PERSON _____________________

BANK ______________________________________________________________________ ADDRESS __________________________________________________________________ PHONE _____________________________ CONTACT PERSON _____________________

CREDIT UNION ____________________________________________________________ ADDRESS__________________________________________________________________ PHONE _____________________________ CONTACT PERSON _____________________

FINANCIAL ADVISOR _____________________________________________________ ADDRESS _________________________________________________________________ PHONE _____________________________ E-MAIL ______________________________

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MINISTER/PASTOR/RABBI/PRIEST _________________________________________ CHURCH/SYNAGOGUE ____________________________________________________ ADDRESS _________________________________________________________________ PHONE _____________________________ E-MAIL ______________________________

DOCTOR ADDRESS _________________________________________________________________ PHONE _____________________________ E-MAIL ______________________________

DOCTOR _________________________________________________________________ ADDRESS _________________________________________________________________ PHONE _____________________________ E-MAIL ______________________________

DOCTOR _________________________________________________________________ ADDRESS _________________________________________________________________ PHONE _____________________________ E-MAIL ______________________________

DENTIST ADDRESS _________________________________________________________________ PHONE _____________________________ E-MAIL ______________________________

CHARITABLE CONCERNS __________________________________________________ ADDRESS _________________________________________________________________ PHONE _____________________________ E-MAIL ______________________________

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LANDLORD ______________________________________________________________ ADDRESS _________________________________________________________________ PHONE _____________________________ E-MAIL ______________________________

Insurance Policies:
LIFE INSURANCE AGENT OR COMPANY _____________________________________ ADDRESS _________________________________________________________________ PHONE ____________________________________________________________________ PERSON INSURED _________________________________________________________ POLICY NUMBER__________________________________________________________ TYPE OF INSURANCE (Circle one):
TERM WHOLE LIFE VARIABLE OR UNIVERSAL LONG TERM CARE GROUP OTHER

DEATH BENEFIT ______________________CASH VALUE? YES____ NO _____ PRIMARY BENEFICIARY____________________________________________________ SECONDARY BENEFICIARY ________________________________________________ LIFE INSURANCE AGENTS OR COMPANIES AGENCY _____________________________________________PHONE ________________ ADDRESS __________________________________________________________________ PERSON INSURED ___________________POLICY NUMBER ______________________ TYPE OF INSURANCE (Circle one)
TERM WHOLE LIFE VARIABLE OR UNIVERSAL LONG TERM CARE GROUP OTHER

DEATH BENEFIT ____________________ CASH VALUE? YES____ NO____ PRIMARY BENEFICIARY____________________________________________________ SECONDARY BENEFICIARY _________________________________________________

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MEDICAL INSURANCE POLICY POLICY NUMBER________________________AGENT ____________________________ COMPANY___________________________________PHONE ________________________ DEATH BENEFIT? YES___ NO ___ AMOUNT _____________________

CAR INSURANCE POLICIES COMPANY______________________________CONTACT___________________________ POLICY NUMBER_________________________PHONE ____________________________ AMOUNT ____________________________________________________________________ LOCATION OF AUTO TITLE(S)________________________________________________

AUTO/HOME/LIABILITY INSURANCE AGENT ___________________________________ COMPANY___________________________________________________________________ ADDRESS ___________________________________________________________________ PHONE _____________________________E-MAIL_________________________________

PENSION/RETIREMENT FUND CONTACT: ______________________________________ NAME _______________________________________________________________________ ADDRESS ___________________________________________________________________ PHONE _____________________________ E-MAIL ________________________________ HOME OWNER’S POLICY COMPANY___________________________________________________________________ POLICY NUMBER_________________________PHONE ___________________________ AGENT______________________________________________________________________

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Government Agencies:
HEALTH AND HUMAN SERVICES (MEDICARE/MEDICAID) PHONE _____________________ CONTACT PERSON________________________

INTERNAL REVENUE SERVICE PHONE ______________________ CONTACT PERSON ________________________

SOCIAL SECURITY ADMINISTRATION PHONE ________________________ CONTACT PERSON __________________________

BUSINESS INTERESTS:
NAME OF BUSINESS_________________________________________________________ ADDRESS ___________________________________________________________________ PHONE _____________________________ E-MAIL ________________________________ TYPE OF ENTITY: (Circle) Sole proprietor Corporation Partnership L.L.C

O WNERS, PARTNEERS, OR MEMBERS _______________________________________ YOUR PERCENTAGE OF OWNERSHIP ________% ARE THERE SHAREHOLDER, PARTNERSHIP, BUY-SELL, OR OTHER AGREEMENTS IN PLACE? YES____ NO _____

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NAME OF BUSINESS _________________________________________________________ ADDRESS ___________________________________________________________________ PHONE _____________________________ E-MAIL ________________________________ TYPE OF ENTITY: (Circle) Sole proprietor Corporation Partnership L.L.C

O WNERS, PARTNEERS, OR MEMBERS _______________________________________ YOUR PERCENTAGE OF OWNERSHIP ________% ARE THERE SHAREHOLDER, PARTNERSHIP, BUY-SELL, OR OTHER AGREEMENTS IN PLACE? YES____ NO _____

NAME OF BUSINESS _________________________________________________________ ADDRESS ___________________________________________________________________ PHONE _____________________________ E-MAIL ________________________________ TYPE OF ENTITY: (Circle) Sole proprietor Corporation Partnership L.L.C

O WNERS, PARTNEERS, OR MEMBERS _______________________________________ YOUR PERCENTAGE OF OWNERSHIP ________% ARE THERE SHAREHOLDER, PARTNERSHIP, BUY-SELL, OR OTHER AGREEMENTS IN PLACE? YES____ NO _____

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Location of Important Items
WILL _______________________________________________________________________ SAFETY DEPOSIT BOX AND KEYS ____________________________________________ _____________________________________________________________________________ OTHER IMPORTANT KEYS ____________________________________________________ _____________________________________________________________________________ CEMETERY DEED ___________________________________________________________ PRE-ARRANGEMENT CONTRACT WITH FUNERAL HOME ______________________ ______________________________________________________________________________ BIRTH CERTIFICATE ________________________________________________________

NATURALIZATION/CITIZENSHIP PAPERS ______________________________________________________________________________ MARRIAGE CERTIFICATE ____________________________________________________ ______________________________________________________________________________

DIVORCE DECREE ___________________________________________________________ ______________________________________________________________________________ NEGOTIABLE PAPERS ________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ MORTGAGE INFO ____________________________________________________________ ______________________________________________________________________________

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CONTRACTUAL AGREEMENTS ________________________________________________ ______________________________________________________________________________ PROMISSORY NOTES _________________________________________________________ ______________________________________________________________________________

INCOME TAX RETURNS _______________________________________________________ ______________________________________________________________________________

Bank Account Information:
NAME OF BANK OR CREDIT UNION ADDRESS OF BRANCH _______________________________________________________ NAMES ON ACCOUNT, ACCOUNT NUMBER, PIN NUMBER/PASSWORD _____________________________________________________________________________ TYPE OF ACCOUNT: CHECKING_____ SAVINGS ______ CD ______ SAFE DEPOSIT ______
AUTOMATIC DEPOSITS OR WITHDRAWLS MADE TO OR FROM THIS ACCOUNT? ____________ ___________________________________________________________________________________________

____________________________________________________________________________

NAME OF BANK OR CREDIT UNION ADDRESS OF BRANCH ______________________________________________________ NAMES ON ACCOUNT, ACCOUNT NUMBERS, PIN NUMBER/PASSWORD ______________________________________________________________________________ TYPE OF ACCOUNT: CHECKING___ SAVINGS ___ CD ___ SAFE DEPOSIT _______
AUTOMATIC DEPOSITS OR WITHDRAWLS MADE TO OR FROM THIS ACCOUNT? _____________ ___________________________________________________________________________________________

_____________________________________________________________________________

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NAME OF BANK OR CREDIT UNION___________________________________________ ADDRESS OF BRANCH _______________________________________________________ NAMES ON ACCOUNT, ACCOUNT NUMBERS, PIN NUMBER/PASSWORD ______________________________________________________________________________ TYPE OF ACCOUNT: CHECKING___ SAVINGS ___ CD ___ SAFE DEPOSIT ______
AUTOMATIC DEPOSITS OR WITHDRAWLS MADE TO OR FROM THIS ACCOUNT? ______________

______________________________________________________________________________ _____________________________________________________________________________ CHECK BOOKS/SAVINGS PASS BOOKS LOCATED _____________________________ _____________________________________________________________________________ CANCELLED CHECKS LOCATED _____________________________________________

Investments:
INVESTMENT COMPANY___________________________________________________ CONTACT PERSON_______________________________PHONE___________________ ON SEPARATE PAGE LIST STOCKS AND BONDS HELD INDIVIDUALLY, NOTING: COMPANY NAME ON STOCK CERTIFICATE NUMBER OF SHARES OWNERS OF SHARES PURCHASE PRICE (IF KNOWN)

TITLE TO MY/OUR STOCKS/BONDS IS AS FOLLOWS: ____________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

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Automatic withdrawals and deposits:
ARE THERE AUTOMATIC PAYMENTS OR WITHDRAWLS GOING INTO, OR COMING FROM, ANY OF YOUR ACCOUNTS? (SOME EXAMPLES: SOCIAL SECURITY PAYMENTS TO YOUR BANK, HOME MORTAGE PAYMENTS FROM YOUR CREDIT UNION, ANNUITY AND/OR PENSION PAYMENTS, ETC.) BE SURE TO INCLUDE ANY TRANSFERS BETWEEN ACCOUNTS, SUCH AS AUTOMATIC TRANSFERS FROM YOUR BANK TO YOUR CREDIT UNION, ETC.

TO________________ OR FROM__________________ ACCOUNT_________________
(Include contact info if not listed elsewhere)

APPROX. AMOUNT $_____________ MONTHLY QUARTERLY ANNUALLY PERIOD OF TRANSFER (circle)

(circle)

INDEFINITELY - UNTIL PAID - OR DATE _____________

TO________________ OR FROM__________________ ACCOUNT_________________
(Include contact info if not listed elsewhere)

APPROX. AMOUNT $_____________ MONTHLY QUARTERLY ANNUALLY (circle) PERIOD OF TRANSFER (circle)
INDEFINITELY - UNTIL PAID - OR DATE______________

TO________________ OR FROM__________________ ACCOUNT_________________
(Include contact info if not listed elsewhere)

APPROX. AMOUNT $_____________ MONTHLY QUARTERLY ANNUALLY (circle) PERIOD OF TRANSFER (circle) INDEFINITELY - UNTIL PAID - OR DATE ______________

Money Owed to You:
1. NAME OF PERSON WHO OWES THE MONEY________________________________ PHONE______________________________DATE DUE _____________________________ ORIGINAL AMOUNT ___________________OUTSTANDING BALANCE____________ IS THERE A PROMISSORY NOTE OR WRITTEN AGREEMENT?

Y___ N_____

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2. NAME OF PERSON WHO OWES THE MONEY________________________________ PHONE______________________________DATE DUE _____________________________ ORIGINAL AMOUNT ___________________OUTSTANDING BALANCE____________ IS THERE A PROMISSORY NOTE OR WRITTEN AGREEMENT?

Y___ N_____

3. NAME OF PERSON WHO OWES THE MONEY________________________________ PHONE______________________________DATE DUE _____________________________ ORIGINAL AMOUNT ___________________OUTSTANDING BALANCE____________ IS THERE A PROMISSORY NOTE OR WRITTEN AGREEMENT?

Y___ N_____

Real Estate:
1. ADDRESS OF PROPERTY __________________________________________________ OWNER(S)__________________________________________________________________ TYPE OF PROPERTY: RESIDENTIAL COMMERCIAL FARM VACANT LAND TIME-SHARE ARE THERE MORTGAGES ON THIS PROPERTY? Y____ N____ IF YES, NAME AND ADDRESS OF LENDER ____________________________________ _____________________________________________________________________________

2. ADDRESS OF PROPERTY ___________________________________________________ OWNER(S)__________________________________________________________________ TYPE OF PROPERTY: RESIDENTIAL COMMERCIAL FARM VACANT LAND TIME-SHARE ARE THERE MORTGAGES ON THIS PROPERTY? Y____ N____ IF YES, NAME AND ADDRESS OF LENDER ____________________________________ _____________________________________________________________________________

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3. ADDRESS OF PROPERTY __________________________________________________ OWNER(S)__________________________________________________________________ TYPE OF PROPERTY: RESIDENTIAL COMMERCIAL FARM VACANT LAND TIME-SHARE ARE THERE MORTGAGES ON THIS PROPERTY? Y____ N____ IF YES, NAME AND ADDRESS OF LENDER ____________________________________

HOME EXPENSES Papers concerning worth of home(s), cost of improvements, etc.
ARE LOCATED_______________________________________________________________

INVENTORY OF HOME FURNISHINGS, LIST MADE (MO/YR) ______________
INDICATES VALUE OF APPROXIMATELY $________________ AND IS LOCATED _____________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________

WALLET CONTENTS: I HAVE MADE A PHOTOCOPY/LIST OF THE CONTENTS OF MY WALLET AND IT IS LOCATED: ______________________________________________________________________________ IF MY WALLET IS NOT FOUND, YOU WILL WANT TO NOTIFY CREDIT COMPANIES THAT THE CARDS ARE LOST (OR NOTE CREDIT CARDS HERE): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 15

Funeral, Memorial, and Burial Arrangements
HAVE FUNERAL PRE-ARRANGEMENTS BEEN MADE? YES _____ NO _____

IF YES, NAME OF FUNERAL HOME __________________________________________ ADDRESS ___________________________________________________________________ PHONE NUMBER _______________ CONTACT PERSON _________________________ LOCATION OF PREARRANGEMENT CONTRACT______________________________ _____________________________________________________________________________ (ATTACH COPY OF ANY CONTRACT INFO TO THIS PAGE.) IF NO CONTRACT, DO YOU HAVE A FUNERAL HOME PREFERENCE? FUNERAL HOME____________________________________________________________ ADDRESS ___________________________________________________________________ PHONE NUMBER________________CONTACT PERSON _________________________ I PREFER BURIAL OR CREMATION? _________________________________________ CHOICE OF CASKET OR URN ________________________________________________ ____________________________________________________________________________ MY WISH FOR DISPOSITION OF ASHES, IF CREMATED (SCATTERING, MAUSOLEUM, BURIAL)_____________________________________________________ IF SCATTERED, IN WHAT SPECIFIC LOCATION, BY WHOM? __________________ ______________________________________________________________________________ ______________________________________________________________________________ (THERE IS A GARDEN AT GUUF WHERE ASHES MAY BE SCATTERED, MEMORIAL TREES
PLANTED, AND SMALL MEMORIAL STONES PLACED.)

NAME AND ADDRESS OF CEMETERY _________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ DO YOU WISH TO BE AN ORGAN DONOR? YES ____ NO ____ 16

DO YOU WISH YOUR BODY OR ORGANS DONATED FOR MEDICAL RESEARCH? YES ____ NO ____ NAME OF INSTITUTION______________________________________________________ CONTACT PERSON__________________________ PHONE _________________________ SECONDARY PLAN IN THE EVENT YOUR BODY IS NOT ACCEPTED: ______________________________________________________________________________ PREFERRED LOCATION FOR FUNERAL/MEMORIAL SERVICE (IF A SERVICE IS DESIRED) ______________________________________________________________________________ PEOPLE YOU WOULD LIKE TO PARTICIPATE IN THE SERVICE ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ PALLBEARERS_______________________________________________________________ ______________________________________________________________________________ FLOWERS: YES____ NO ____ BURIAL CLOTHING __________________________________________________________ ______________________________________________________________________________

CHOICE OF MUSIC FOR SERVICE (TAPE, CD, MUSICIANS, ETC.)________________ ______________________________________________________________________________ ______________________________________________________________________________

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CHOICE OF READINGS FOR SERVICE _______________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ SUGGEST MEMORIAL DONATIONS GO TO ____________________________________ ______________________________________________________________________________ ______________________________________________________________________________ DISCUSS ANY FURTHER INSTRUCTIONS YOU’D LIKE TO SHARE WITH YOUR FAMILY AND FRIENDS CONCERNING YOUR FUNERAL OR MEMORIAL SERVICE. OR WRITE A MESSAGE TO ANYONE SIGNIFICANT TO YOU. _____________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

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Write your own obituary, or list anything you would like to have included
in your obituary.
(SUGGESTIONS: SCHOOLS ATTENDED, AWARDS, NAMES OF EXTENDED FAMILY AND THEIR RELATIONSHIP TO YOU, NAMES OF CLOSE FAMILY MEMBERS WHO HAVE PREDECEASED YOU, PRIOR MARRIAGES, CHURCH AFFILIATION, FRATERNAL AFFILIATIONS, HOBBIES, TRAVELS, MILITARY OR FRATERNAL AFFILIATIONS, MEMORIAL REMEMBRANCE)

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Use this sheet for additional information. (If referring to a question on the form, please include the page number for cross reference.)

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