Member-National Academy of Elder Law Attorneys, Inc.                                   www.texaselderlawattorney.com

MY PERSONAL RECORDS

Use this workbook to keep track of your personal records and information for your loved ones. Knowing this information will be helpful to your executor, agent and family if you die or become incapacitated. Keep these records in a safe place. Make sure an appropriate person knows where to look for them. Be sure to update these records from time to time.

We can assist you with your estate planning, probate, trust and long term care needs. Please give us a call at 1-800-939-9093 if we can be of assistance.

Contents Page

1. Information Regarding These Records 1
2. Personal Information 1
3. My Estate Planning Documents 5
4. Insurance 7
5. My Assets and Liabilities 8
6. Burial 13
7. Persons Familiar With My Affairs 14

1. Information Regarding These Records

This information was entered in this workbook on _________________________________, 20____, by __________________________________________________________.

It has been revised or reviewed as follows: (List Dates)
1.____________________________ 2.______________________________

The original of these records is kept: (Give Location) __________________________________________________

(If Applicable) A copy of these records is kept: (Give Location) _____________________________________________

2. Personal Information

My legal residence is:

_________________________ _________________________ __________________________
City State County

Date of Birth:

__________ __________ __________
Month Day Year


Place of Birth:

_________________________ _________________________ __________________________
City State County

Birth Records are located at:______________________________________________________________________

Social Security Number:_______________________________

Card located at:_________________________________________________________________________________

If citizen of Foreign Country Date entered USA:_____________________

Citizen Papers are located at:______________________________________________________________________


I currently am Married to:______________________ _______________________ ______________________
First Last Maiden

Wedding:__________ __________ __________ At: ____________ _____________ _____________
Month Day Year City State County

Birth Date of Spouse:__________ __________ __________
Month Day Year

Place of Birth:_________________________ ________________________ ________________________
City State County

My Children are: (List Name, Birth Date and Current Address)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             

If no children, list brothers and sisters:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    

Former Marriages (list all):

Former Spouse:______________________ _______________________ ______________________
First Last Maiden

If marriage ended in death:__________ __________ __________
Month Day Year

Cause of death:__________________________ _______________________ _____________
Cause City Age

If marriage ended in divorce:__________ __________ __________
Month Day Year

Place of Divorce: _________________________________ ___________________________________
City State

Records at:____________________________________________________________________________________

Attorney:______________________________________________________________________________________


Former Spouse:______________________ _______________________ ______________________
First Last Maiden

If marriage ended in death:__________ __________ __________
Month Day Year

Cause of death:__________________________ _______________________ _____________
Cause City Age

If marriage ended in divorce:__________ __________ __________
Month Day Year

Place of Divorce: _________________________________ ___________________________________
City State

Records at:____________________________________________________________________________________

Attorney:______________________________________________________________________________________


Parents:

Father (name):______________________ _______________________ _______________________
First Middle Last

Born: __________ __________ __________ _______________________________
Month Day Year Place

Died: __________ __________ __________ _______________________________
Month Day Year Place

Buried at: __________ __________ __________ _______________________________
Month Day Year Place

Mother (name):______________________ _______________________ ______________________________
First Middle Last (include Maiden)

Born: __________ __________ __________ _______________________________
Month Day Year Place

Died: __________ __________ __________ _______________________________
Month Day Year Place

Buried at: __________ __________ __________ _______________________________
Month Day Year Place

Military Service:

No military service

Branch of:_____________________

Service:_______________________ Country:________________________

From: _______________________ To:______________________

Date of Discharge:________________________ Type of Discharge:___________________________

Highest Grade
Or Rank attained:_________________________

Employment:

My present employer is:_____________________________________________________________________________
Name, address and phone number

Date Started:_____________________________ Supervisor:__________________________________

In addition, I am eligible under the following pension, profit sharing and other benefit plans:

1.

2.

3.

4.

I am ________ am not _________ a member of a Labor Union.

Name of Local:________________________________________________________________________________

______________________________________________________ ______________________
Address Phone

I am ________ am not _________ a member of a Credit Union.

Name of Local:________________________________________________________________________________

______________________________________________________ ______________________
Address Phone

3. My Estate Planning Documents

My Will:

Original executed copy of my will is located at:________________________________________________________

It is dated:__________ __________ __________
Month Day Year

The original executed Codicil (if any), is located at:_____________________________________________________

It is dated:__________ __________ __________
Month Day Year

Attorney who drew my will is:______________________________________________________________________

Name(s) of Executor(s) and Trustee(s):                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             

Executor(s)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
 

Trustee(s)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             

Names of Guardians of my Children:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             

Witnesses to Will (list names and addresses):                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             

My Directive to Physicians and Family or Surrogates (“Living Will”):

I have a “Living Will”__________ I have no “Living Will”__________

The original is located at:_________________________________________________________________________

It is dated:__________ __________ __________
Month Day Year

My Medical Power of Attorney:

I have a Medical Power of Attorney___________ I have no such power___________

The original is located at:_________________________________________________________________________

It is dated:__________ __________ __________
Month Day Year

My Durable Power of Attorney for Property:

I have a Durable Power of Attorney for Property___________ I have no such power___________

The original is located at:_________________________________________________________________________

It is dated:__________ __________ __________
Month Day Year

My Declaration of Guardian:

I have a Declaration of Guardian___________ I have no Declaration of Guardian___________

The original is located at:_________________________________________________________________________

It is dated:__________ __________ __________
Month Day Year

My Trust(s):

I have created (or am a beneficiary of) the following trust(s):

Trust Name:___________________________________________________________________________________

It is dated:__________ __________ __________
Month Day Year

Original Trust Instrument is located at:_______________________________________________________________

Name and Address of current Trustee:__________________________________________________________________

Name and Address of Successor Trustee:_____________________________________________________________

Trust Name:___________________________________________________________________________________

It is dated:__________ __________ __________
Month Day Year

Original Trust Instrument is located at:_______________________________________________________________

Name and Address of current Trustee:__________________________________________________________________

Name and Address of Successor Trustee:_____________________________________________________________

Other Estate Planning Documents: (Please described and state location)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    

4. Insurance

Life Insurance:

I do do not have Life Insurance.

Complete itemized list can be found:________________________________________________________________

Policies are located at:___________________________________________________________________________

Policies Covering Others:

I own insurance policies on the lives of others. A list of companies and policy numbers is located at:
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                

Name of persons insured:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  

I have __________ have not ___________ made loans against some of the policies.

Source of loan:___________________________________________________________________________________

Address:________________________________________________________________________________

Pertinent papers are filed with the policies: (Check)
___ Endorsements ___ Dividend Payments
___ Premium Receipts ___ Assignments
___ Settlement Agreements

Annuities:

I do do not have annuities.

Detailed list is located at:__________________________________________________________________________

Location of annuity contracts:_______________________________________________________________________

My principal life insurance broker is:__________________________________________________________________
Name, Address and Phone

Medical and Long Term Care Insurance:

Accident, Hospitalization, Disability, Long term care and all other insurance (in addition to and exclusive of those covered by my employer) not noted elsewhere:

Location of List:________________________________________________________________________________

Location of Policies:_____________________________________________________________________________

Broker/Agent:__________________________________________________________________________________
Name, Address and Phone

Medicare:

I am am not registered for Medicare.

Enrollment ___________ at ___________________ _____________________
Date City State

Medicare card located at:____________________________________________________________________________

5. My Assets and Liabilities

Safe Deposit Boxes:


I have have not a safe deposit box.

Located at:______________________________________________________________________________________

Keys will be found at:______________________________________________________________________________

The following person has access (Name and Address):____________________________________________________

Accounts:

Checking
Accounts:_________________________________________________ _____________________________
With Number

__________________________________________________ _____________________________
With Number

Savings
Accounts:_________________________________________________ _____________________________
With Number

__________________________________________________ _____________________________
With Number

Other
Accounts:_________________________________________________ _____________________________
With Number

__________________________________________________ _____________________________
With Number

__________________________________________________ _____________________________
With Number

Passbooks located at:______________________________________________________________________________

Accounts in joint names with myself and (Name and Acct. No.):                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

Name of person who has power to sign checks for me (Name, Address and Phone):___________________________

Real Estate:

I do do not own real estate. I am the sole owner.

It is located at:___________________________________________________________________________________

Mortgage on my residence is held by:_________________________________________________________________

The following documents are located at:________________________________________________________________

___ Deed ___ Mortgage Insurance Policy
___ Copy of Mortgage ___ Title Abstract
___ Improvement Loans ___ Closing Statement
___ Title Insurance ___ Leases
___ Tax Receipts ___ Maps & Surveys

Other Real Estate I own: I am the sole owner.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  

Documents pertaining thereto are located at:___________________________________________________________

Insurance Coverage is handled by:___________________________________________________________________

Name of Agent:_________________________________________________________________________________
Name, Address and Phone

Policies are located at:____________________________________________________________________________

I lease property to others: Yes No

Vacant Improved

To:_____________________________________________________________________________________________
Name, Address and Phone

At (list location):_________________________________________________________________________________

Leases can be found at:____________________________________________________________________________

U.S. Savings Bonds:

I do do not own U.S. Savings Bonds.

List of Bonds - Serial Numbers - Co-ownership - and who is a Beneficiary at my death can be found at:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                

Bonds are located at:_____________________________________________________________________________

Securities:

I do do not own Securities (stocks and bonds).

List of Securities and certificate numbers can be found at:



Certificates are located at:__________________________________________________________________________

I do do not have a brokerage account.

Name of Broker or Firm:__________________________________________________________________________
Name, Address and Phone

Records of Purchase and Sale are located at:__________________________________________________________

List Securities pledged for loans with:________________________________________________________________
Lender Address

___________________________________________________________________
Lender Address

Personal Property:

I own the following personal property:

Auto: Yes No

1.___________________________ ___________
Make Year

2.___________________________ ___________
Make Year

Title(s) located at:________________________________________________________________________________

Household furnishings: Yes No

Located at:______________________________________________________________________________________

Record of Inventory located at:_____________________________________________________________________

Jewelry: Yes No

Inventory List & Appraisals located at:________________________________________________________________

Boat: Yes No

___________________________ ___________
Make Year

Located at:______________________________________________________________________________________

Miscellaneous Personal Property (not previously listed):                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   

Pertinent insurance policies on personal property are located at:___________________________________________

Insurance Agent:_________________________________________________________________________________
Name, Address and Phone

Proof of ownership, receipts, bills of sale, etc. are located at:_______________________________________________

Miscellaneous Assets:

List here other assets you own that are not otherwise covered above:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    

Credit Cards:

I possess the following credit cards:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             

Other Liabilities:

Mortgages, notes, and other debts not noted elsewhere:

Description:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   

Copies of previous years’ tax returns filed are located at:________________________________________________

Party who prepared or assisted in tax returns:__________________________________________________________

Work sheets and evidence in support of returns are located at:______________________________________________

Current withholding tax forms and receipts received from my employer are located at:___________________________

6. Burial

(Please note. A special form is required to leave binding burial instructions. You can indicate your wishes here, but those indications are not binding on your family. Ask for more information.)

I do _______ do not ________ own a cemetery lot.

Cemetery Lot:___________________________________________________________________________________
Name of Cemetery Describe location

Deed located at:________________________________________________________________________________

There _______ is not _______ provision for perpetual care.

I have given instructions regarding my funeral in:______________________________________________________

Letter Other:____________________________________________________________________________

List membership in lodges or fraternal organizations providing cemetery benefits:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  

My preference for burial would be at:_______________________________________________________________
Name of Cemetery City

Religious Affiliation (List Church or Temple and Address):________________________________________________

Pastor or Rabbi:_________________________________________________________________________________
Name, Phone

7. Persons Familiar With My Affairs

Please print name, address and phone number.

Attorney:______________________________________________________________________________________

Accountant - Tax Counselors:_____________________________________________________________________

Banker:_______________________________________________________________________________________

Doctor:_______________________________________________________________________________________

Employer:_____________________________________________________________________________________

Funeral Director:________________________________________________________________________________

Insurance Agent:_________________________________________________________________________________

Executor of Estate:_______________________________________________________________________________

Fraternal or Professional Groups (Please Notify):______________________________________________________

Relatives and Personal Friends (Please Notify:_________________________________________________________

Legal Disclaimer

This information has been provided for informational purposes only.  It does not constitute legal advice.  The receipt of this information does not establish an attorney-client privilege.  Proper legal advice can only be given upon consideration of all the relevant facts and the law.  Therefore, you should not act upon any information contained herein without seeking appropriate legal counsel.  

Richard M. Barron

Attorney at Law

209 E. Main Street

Whitesboro, Texas 76273

903-564-3663, 940 612-3663, 800-939-9093

Fax - 903-564-5562

Email- [email protected]

Not certified by the Texas Board of Legal Specialization

Licensed to Practice Law by the Supreme Court of Texas