"Durable Medical Power of Attorney"
NCACU Estate Planning Work Sheet Page 1 IMPORTANT Keeping accurate records can help you stay organized and provide important information in case of an emergency. Keep this information in a safe place and only share the content and location of this work sheet with Estate Planning Work Sheet Date: Full Legal Name: Social Security Number: Health and Medical Care Account # Address Phone Number Health Insurance Medicare supplement Medicare Number Medicaid Number Other Doctor's Names Specialty Address Phone Number Dentist Eye care Health Care/In-Home Providers Service Address Phone Number NCACU Estate Planning Work Sheet Page 2 Current Medications Dosage Instructions Pharmacy ID Legal and Financial Information Date Location of Document Filed with Will Living Will Power of Attorney Durable medical Power of Attorney Health Care Proxy Birth Certificate Divorce Decree Property Deed Save Deposit Box Location of Keys Other Other Other Source of Income Address Phone number Monthly Amount Employment Employment Social Security Retirement Pension Other Other Other Bank Accounts Address Phone Number Account Number Checking Savings Savings Other NCACU Estate Planning Work Sheet Page 3 Investments Address Phone Number Account Number Stocks Stocks Bonds Bonds Annuities CD CD IRA IRA Mutual Funds Money Market Other Other Accountant/Financial Planer Name Address Phone Number Insurance/Policy Number Agent Address Phone Number Life Health Medigap Disability Long Term Care Dental Optical Home Owners/Rental Liability Automobile Other Funeral/Burial Instructions NCACU Estate Planning Work Sheet Page 4 Clergy Church Address Phone Number Close Friends and Family Relationship Address Phone Number Name of Beneficiary Items Address Phone Number Notes: Keep this information in a safe NEED HELP? Financial Counseling Assistance: Grayling 989-348-7488; Houghton Lake 989-366-9646; Roscommon 989-275-5169; Standish - 989-846-9553. Eric Reed ,LPL Financial , Registered Rep - 989-345-5800.