Durable Medical Power of Attorney by mtb29869

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									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.

								
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