Register

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Prepared:

Updated:

If found, do not discard. This book has a home.

Let us return it to the rightful owner. www.MemoryBanc.com

For:

Date Initials

Date Initials

Date Initials

Date Initials

Date Initials

Date Initials

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There are just too many things to remember. I developed this book in hopes of helping better support my parents, but found it useful to help manage all of my own important documents and details. From bank accounts to visits to the doctor, this is now a system I use for my family. I hope you find it helps yours. If you have specific suggestions on how to improve this system or update it for some additional items that are important to you, Id love to hear from you. My email is Kay@MemoryBanc.com.

Sincerely,

Kay BransfordFounderMemoryBanc

How to Use MemoryBanc Register

1) Complete the following pages and store this book in a safe place. If you want us to store your important documents, visit www.MemoryBanc.com. 2) Tell those you trust where to find this book if needed. 3) Review this book every year.

You will find duplicates of many of the pages I frequently update. Feel free to make copies, or reorder more inserts as you need.

Using the Register Jointly

You can easily use this book to manage joint details by making copies of these pages and noting the individual at the top of the page. We also offer a version for couples with duplicate pages and additional tab separators.

Using the Register for Multiple Properties

You can make a copy of the sections (Utilities and Other Services) and note the specific Account Service Address at the top of each page to which these accounts apply.

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Personal Profile Name Social Security Number Birth Date

Self: ________-______-___________ ______/______/_________

Spouse: ________-______-___________ ______/______/_________

Children: ________-______-___________ ______/______/_________

________-______-___________ ______/______/_________

________-______-___________ ______/______/_________

________-______-___________ ______/______/_________

________-______-___________ ______/______/_________

________-______-___________ ______/______/_________

OTHER BENEFICIARIES

________-______-___________ ______/______/_________

________-______-___________ ______/______/_________

CONTACT INFORMATION

Home Address: _______________________________________________________________________________________________

_______________________________________________________________________________________________

Home Phone: ( ) ___________-_______________

Personal Mobile: ( ) ___________-_______________ Personal Email: ________________________________

Business Address: ____________________________________________________________________________________________

____________________________________________________________________________________________

Business Phone: ( ) ___________-_______________

Business Mobile: ( ) ___________-_______________ Business Email: ________________________________

City State Zip

City State Zip

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Key Contacts & AdvisorsFINANCIAL ADVISOR

Name / Company: ____________________________________________________________________________________________

Phone: ( ) ___________-_______________ Email: ___________________________________________________

Address: ______________________________________________________________________________________________

Related Documents held by Financial Advisor: ________________________________________________________

My copies of documents and materials are stored: ____________________________________________________

ATTORNEY

Name / Company: ____________________________________________________________________________________________

Phone: ( ) ___________-_______________ Email: ___________________________________________________

Address: ______________________________________________________________________________________________

Related Documents held by Attorney: _________________________________________________________________

My copies of documents and materials are stored: ____________________________________________________

ACCOUNTANT

Name / Company: ____________________________________________________________________________________________

Phone: ( ) ___________-_______________ Email: ___________________________________________________

Address: ______________________________________________________________________________________________

Related Documents held by Accountant: ______________________________________________________________

My copies of documents and materials are stored: ____________________________________________________

INSURANCE AGENT

Name / Company: ____________________________________________________________________________________________

Phone: ( ) ___________-_______________ Email: ___________________________________________________

Address: ______________________________________________________________________________________________

Related Documents held by Insurance Agent: _________________________________________________________

My copies of documents and materials are stored: ____________________________________________________

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Key Contacts & Advisors (cont.)PERSONAL REPRESENTATIVE / EXECUTOR

Name / Company: ____________________________________________________________________________________________

Phone: ( ) ___________-_______________ Email: ___________________________________________________

Address: ______________________________________________________________________________________________

Related Documents held by Representative: __________________________________________________________

My copies of documents and materials are stored: ____________________________________________________

SPIRITUAL / CLERGY

Name / Company: ____________________________________________________________________________________________

Phone: ( ) ___________-_______________ Email: ___________________________________________________

Address: ______________________________________________________________________________________________

Related Documents held by Spiritual/Clergy: _________________________________________________________

My copies of documents and materials are stored: ____________________________________________________

OTHER

In the event you become incapacitated or are disabled and unable to manage your own affairs, list someone

other than a spouse to act as guardian and / or trustee:

Name: ________________________________________________________________________________________________________

Phone: ( ) ___________-_______________ Email: ___________________________________________________

Address: ______________________________________________________________________________________________

ADDITIONAL CONTACT

Name / Company: ____________________________________________________________________________________________

Phone: ( ) ___________-_______________ Email: ___________________________________________________

Address: ______________________________________________________________________________________________

Related Documents held by Contact: _________________________________________________________________

My copies of documents and materials are stored: ____________________________________________________

Please visit the Medical section of this binder to record all doctors, dentists, therapists and other individuals related to your medical care.

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Location of Important Personal Documents Last Updated Location

Birth Certificate Not applicable ______________________________________________________

Marriage Certificate Not applicable ______________________________________________________

Will ______/______/_________ ______________________________________________________

Durable Power of Attorney ______/______/_________ ______________________________________________________

Health Care Directive ______/______/_________ ______________________________________________________

Living Will ______/______/_________ ______________________________________________________

Revocable Living Trust ______/______/_________ ______________________________________________________

Burial Instructions ______/______/_________ ______________________________________________________

Tax Returns (Years / Location): ________________________________________________________________________________

_________________________________________________________________________________________________________________

Appraisals and / or inventory of personal property: ____________________________________________________________

_________________________________________________________________________________________________________________

Safe Deposit Box (Company): __________________________________________________________________________________

Address: ______________________________________________________________________________________________

Phone: ( ) ___________-_______________ Contact: _________________________________________________

Names of those authorized to open up safe deposit box: ______________________________________________

________________________________________________________________________________________________________

Location of key(s): ____________________________________________________________________________________

Contents: _____________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

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Licenses & Certifications Expiration License # Location

Drivers License ______/______/_________ _____________________ _____________________________

Other: ________________________ ______/______/_________ _____________________ _____________________________

Other: ________________________ ______/______/_________ _____________________ _____________________________

Other: ________________________ ______/______/_________ _____________________ _____________________________

Other: ________________________ ______/______/_________ _____________________ _____________________________

Additional related details or important information regarding these licenses and certifications:

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

__________________________________________________________ ______________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

____ ____________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

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Medical

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____________________________

Name InsuranceHealth Insurance

Provider Name: ______________________________________ Provider Phone: ( ) ___________-_______________

Provider Address: ________________________________________________________________________________________

Policy #: ___________________________ Group #: _________________________________

Co-pay: ___________ Cost / Month: $_________

Website: _____________________ Pin: _____ Username: __________________ Password: ____________

If you are not the primary insured on this account, detail:

Primary Insureds Name: ________________________________________________________

Primary Insureds Date of Birth: ______/______/_________ Social Security Number: ________-______-___________

Supplemental Health Insurance

Provider Name: ______________________________________ Provider Phone: ( ) ___________-_______________

Provider Address: ________________________________________________________________________________________

Policy #: ___________________________ Group #: _________________________________

Co-pay: ___________ Cost / Month: $_________

Website: _____________________ Pin: _____ Username: __________________ Password: ____________

If you are not the primary insured on this account, detail:

Primary Insureds Name: ________________________________________________________

Primary Insureds Date of Birth: ______/______/_________

Dental Insurance (if different)

Provider Name: ______________________________________ Provider Phone: ( ) ___________-_______________

Provider Address: ________________________________________________________________________________________

Policy #: ___________________________ Group #: _________________________________

Co-pay: ___________ Cost / Month: $_________

Website: _____________________ Pin: _____ Username: __________________ Password: ____________

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Insurance (cont.)Long-Term Care Insurance

Provider Name: ______________________________________ Provider Phone: ( ) ___________-_______________

Provider Address: ________________________________________________________________________________________

Policy #: ___________________________ Group #: _________________________________

Co-pay: ___________ Cost / Month: $_________

Website: _____________________ Pin: _____ Username: __________________ Password: ____________

Disability Insurance

Provider Name: ______________________________________ Provider Phone: ( ) ___________-_______________

Provider Address: ________________________________________________________________________________________

Policy #: ___________________________ Group #: _________________________________

Co-pay: __________ Cost / Month: $_______

Website: _______________ Pin: _____ Username: ________________ Password: _______

Other: ______________________________________________________________

Account Holder (if other than yourself): _______________________________________________________________________

Provider Name: ___________________________________________________ Phone: ( ) ___________-_______________

Provider Address: _____________________________________________________________________________________________

Policy #: __________________________________________________ Group #: __________________________________________

Notes: _________________________________________________________________________________________________________

Other: ______________________________________________________________

Account Holder (if other than yourself): _______________________________________________________________________

Provider Name: ___________________________________________________ Phone: ( ) ___________-_______________

Provider Address: _____________________________________________________________________________________________

Policy #: __________________________________________________ Group #: __________________________________________

Notes: _________________________________________________________________________________________________________

Additional related details or important information regarding these accounts:

________________________________________________________________________________________________________________

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____________________________

Name Health Care Providers

Details for all doctors, dentists, therapists and alternative healing contacts:

Primary Care Physician

Name / Practice: __________________________________________________ Phone: ( ) ___________-_______________

Address: ______________________________________________________________________________________________________

Email: ___________________________________________ Hours: _____________________________________________________

Notes: ______________________________________________________________________

Dentist

Name / Practice: __________________________________________________ Phone: ( ) ___________-_______________

Address: ______________________________________________________________________________________________________

Email: ___________________________________________ Hours: _____________________________________________________

Notes: ______________________________________________________________________

Other: ____________________________________________________________

Name / Practice: __________________________________________________ Phone: ( ) ___________-_______________

Address: ______________________________________________________________________________________________________

Email: ___________________________________________ Hours: _____________________________________________________

Notes: ______________________________________________________________________

Other: ____________________________________________________________

Name / Practice: __________________________________________________ Phone: ( ) ___________-_______________

Address: ______________________________________________________________________________________________________

Email: ___________________________________________ Hours: _____________________________________________________

Notes: ______________________________________________________________________

Other: ____________________________________________________________

Name / Practice: __________________________________________________ Phone: ( ) ___________-_______________

Address: ______________________________________________________________________________________________________

Email: ___________________________________________ Hours: _____________________________________________________

Notes: ______________________________________________________________________

(Specify services provided and root cause for seeing this individual / practice)

(Specify services provided and root cause for seeing this individual / practice)

(Specify services provided and root cause for seeing this individual / practice)

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Current Medications and SupplementsMedications

Supplements: Vitamins, Herbs and Other Supplements

Prescription Treats Dose Times Per DayInclude Prescribing Physician

Name of Supplement Purpose Dose Times Per Day

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____________________________

Name Personal Medical HistoryI have had the following medical problems and have noted approximate date of illness or diagnosis:

______ Congenital Heart Disease; Type: _______________________________

______ Myocardial Infarction (Heart Attack) Date(s) of occurrence(s): ______________________

______ Hypertension (High Blood Pressure)

______ Diabetes

______ High Cholesterol

______ Stroke Date(s) of occurrence(s): ______________________

______ Thyroid problem; Type: ________________________________________

______ Coagulation (Bleeding / Clotting) Disorder

______ Cancer; Type: ________________________________________

______ Depression/Suicide Attempt

______ Alcoholism

______ Other: ________________________________________

______ Other: ________________________________________

Additional notes related to the above information:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Have you ever had a blood transfusion? If so, when: ___________________

Currently Prescribed Treatments:

_____Oral Antihistamine _____EpiPen _____Other

Known Allergies or Reactions to Reaction or Side Effect Medicines / Foods / Other

Diagnosed: ___________________________

Diagnosed: ___________________________

Diagnosed: ___________________________

Diagnosed: ___________________________

Diagnosed: ___________________________

Diagnosed: ___________________________

Diagnosed: ___________________________

Diagnosed: ___________________________

Diagnosed: ___________________________

Diagnosed: ___________________________

Diagnosed: ___________________________

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Personal Medical History (cont.)

SOCIAL HISTORY

Tobacco Use

Cigarettes: Start Date: ______/______/_________ Quit Date: ______/______/_________ _____ Packs a Day

Other Tobacco: Start Date: ______/______/_________ Quit Date: ______/______/___________

____ Pipe ____ Cigar ____ Snuff ____ Chew

Alcohol Use: Start Date: ______/______/_________ Quit Date: ______/______/_________ _____ Drinks/Week

Exercise: Do you exercise regularly?______________ How often? _____________________________________

WOMENS GYNECOLOGIC HISTORY

______ # of Pregnancies ______ # of Deliveries ______ # of Miscarriages

Age periods began: ____________ Age periods ended: ____________

Abnormal Pap Smear? Date: ______/______/_________

Other problems not listed that are important in regard to your health:

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Surgical History Date

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____________________________

Name Family Medical HistoryMEDICAL CONDITION Mom Dad Sis. Bro. Dau. Son Other

Alcoholism

Anemia

Anesthesia Problem

Arthritis

Asthma

Birth Defects

Bleeding Problem

Cancer (Breast)

Cancer (Colon)

Cancer (Melanoma)

Cancer (Skin)

Cancer (Ovary)

Cancer (Prostate)

Cancer (Not noted)

Depression

Diabetes (Type 1)

Diabetes (Type 2)

Eczema

Epilepsy / Seizures

Genetic Diseases

Glaucoma

Hay Fever / Rhinitis

Hearing Problems

Heart Attack

High Blood Pressure

High Cholesterol

Kidney Disease

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MEDICAL CONDITION Mom Dad Sis. Bro. Dau. Son Other

Lupus

Mental Retardation

Migraine Headaches

Mitral Valve Prolapse

Osteoarthritis

Osteoporosis

Rheumatoid Arthritis

Stroke

Thyroid Disorder

Tuberculosis

Other:

Other:

Other:

Additional notes on any of the listed conditions: ________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Organ Donation? Yes / No

_________________________

_________________________

Family Medical History (cont.)

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____________________________

Name ImmunizationsPlease list the most recent date of the following immunizations or best estimate of year if unknown.

Annual Flu Shot: ______; ______; ______; ______; ______; ______; ______; ______; _______

Hepatitis A: ______/______/_________; ______/______/_________; ______/______/_________

Hepatitis B: ______/______/_________; ______/______/_________; ______/______/_________

Tetanus (Td): ______/______/_________; ______/______/_________; ______/______/_________

Pneumonia: ______/______/_________; ______/______/_________; ______/______/_________

Measles: ______/______/_________; ______/______/_________; ______/______/_________

Mumps: ______/______/_________; ______/______/_________; ______/______/_________

Rubella: ______/______/_________; ______/______/_________; ______/______/_________

MMR: ______/______/_________; ______/______/_________; ______/______/_________

Varicella (Chicken Pox): ______/______/_________; ______/______/_________; ______/______/_________

Shingles: ______/______/_________; ______/______/_________; ______/______/_________

Other: ___________________________ ______/______/_________; ______/______/_________; ______/______/_________

Other: ___________________________ ______/______/_________; ______/______/_________; ______/______/_________

Other: ___________________________ ______/______/_________; ______/______/_________; ______/______/_________

Other: ___________________________ ______/______/_________; ______/______/_________; ______/______/_________

Other: ___________________________ ______/______/_________; ______/______/_________; ______/______/_________

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____________________________

Name Doctors VisitDate of Visit: ______/______/_________ Doctor Visited: ___________________________________________________________

Scheduled for: ________________________________________________________________________________________

Form Completed by: __________________________________________________________________________________

If the appointment was based on a specific complaint or one was reported at the time of the visit: ____________

_________________________________________________________________________________________________________________

When did it start? ______/______/_________ What are the symptoms? ____________________________________________

If you have pain, is it a dull ache or stabbing pain? _____________________________________________________________

Have you had this problem before? _________________________ When? __________________________________________

What did you do for it? ________________________________________________________________________

Have there been any recent changes in your life (stress, medicines, food, exercise, etc.)?

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Does anyone else at home or work have these symptoms? ____________________________________________________

How concerned are you about the problem? ___________________________________________________________________

VITAL SIGNS

Weight: ______________________

Temperature: ______________________

Pulse: ______________________

Blood Pressure: ______________________

DIAGNOSIS

What was the diagnosis? ______________________________________________________________________________________

What is the recommended treatment? _________________________________________________________________________

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Doctors Visit (cont.)What might happen next? _____________________________________________________________________________________

Does this create any issues or limitations? ____________________________________________________________________

_________________________________________________________________________________________________________________

If additional medication, tests and treatments were prescribed:

Whats the name of the medicine? ____________________________________________________________________

How do I take this? ____________________________________________________________________________________

Why do I need it? ______________________________________________________________________________________

________________________________________________________________________________________________________

What are the risks? ___________________________________________________________________________________

________________________________________________________________________________________________________

Are there alternatives? ________________________________________________________________________________

________________________________________________________________________________________________________

Is any follow-up testing required? If so, what is it? ____________________________

How do I prepare for it? _______________________________________________________________________________

Can I phone in for test results? ________________________________________________________________________

What happens if I do nothing? _________________________________________________________________________

________________________________________________________________________________________________________

NEXT STEPS

Do I need to return for another visit? __________________________________________________________________________

Are there any danger signs to watch for? ______________________________________________________________________

Do I need to report back about my condition? __________________________________________________________________

What else do I need to know? __________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

www.MemoryBanc.com

____________________________

Name Doctors VisitDate of Visit: ______/______/_________ Doctor Visited: ___________________________________________________________

Scheduled for: ________________________________________________________________________________________

Form Completed by: __________________________________________________________________________________

If the appointment was based on a specific complaint or one was reported at the time of the visit: ____________

_________________________________________________________________________________________________________________

When did it start? ______/______/_________ What are the symptoms? ____________________________________________

If you have pain, is it a dull ache or stabbing pain? _____________________________________________________________

Have you had this problem before? _________________________ When? __________________________________________

What did you do for it? ________________________________________________________________________

Have there been any recent changes in your life (stress, medicines, food, exercise, etc.)?

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Does anyone else at home or work have these symptoms? ____________________________________________________

How concerned are you about the problem? ___________________________________________________________________

VITAL SIGNS

Weight: ______________________

Temperature: ______________________

Pulse: ______________________

Blood Pressure: ______________________

DIAGNOSIS

What was the diagnosis? ______________________________________________________________________________________

What is the recommended treatment? _________________________________________________________________________

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Doctors Visit (cont.)What might happen next? _____________________________________________________________________________________

Does this create any issues or limitations? ____________________________________________________________________

_________________________________________________________________________________________________________________

If additional medication, tests and treatments were prescribed:

Whats the name of the medicine? ____________________________________________________________________

How do I take this? ____________________________________________________________________________________

Why do I need it? ______________________________________________________________________________________

________________________________________________________________________________________________________

What are the risks? ___________________________________________________________________________________

________________________________________________________________________________________________________

Are there alternatives? ________________________________________________________________________________

________________________________________________________________________________________________________

Is any follow-up testing required? If so, what is it? ____________________________

How do I prepare for it? _______________________________________________________________________________

Can I phone in for test results? ________________________________________________________________________

What happens if I do nothing? _________________________________________________________________________

________________________________________________________________________________________________________

NEXT STEPS

Do I need to return for another visit? __________________________________________________________________________

Are there any danger signs to watch for? ______________________________________________________________________

Do I need to report back about my condition? __________________________________________________________________

What else do I need to know? __________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

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Roster of Medical Professionals for Specific Care NeedsCreated by: Heike Kessler-Heiberg, MA-CCC 2011

Name: ___________________________ DOB: ______/______/_________ Date Completed: ______/______/________

I would like this note to be placed in and maintained in my medical records for present use and future reference.

Signed: _____________________________________________

I am working with the following doctors, dentists, therapists, specialists, mental health providers and alternative healers, etc.

NAME SPECIALTY ADDRESS PHONE

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Roster of Prescriptions and SupplementsCreated by: Heike Kessler-Heiberg, MA-CCC 2011

Name: ___________________________ DOB: ______/______/_________ Date Completed: ______/______/_______

I would like this note to be placed in and maintained in my medical records for present use and future reference.

Signed: ____________________________________________

Prescription Treats Dose Times Per DayInclude Prescribing Physician

Name of Supplement Purpose Dose Times Per Day

Financial

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____________________________

Name Bank & Investment AccountsBank / Institution: _______________________________________________________________________________________

Title (Names) on Account: ________________________________________________________________________

Contact Name: ________________________________ Phone: _________________

AccountNumber:___________________________ Type of Account: _________________________________

___________________________________________________________________________________

___________________________________________________________________________________

AccountNumber:___________________________ Type of Account: _________________________________

___________________________________________________________________________________

___________________________________________________________________________________

AccountNumber:___________________________ Type of Account: _________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Bank / Institution: _______________________________________________________________________________________

Title (Names) on Account: ________________________________________________________________________

Contact Name: ________________________________ Phone: _________________

AccountNumber:___________________________ Type of Account: _________________________________

___________________________________________________________________________________

___________________________________________________________________________________

AccountNumber:___________________________ Type of Account: _________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Additional related details or important information regarding these accounts:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

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Bank & Investment Accounts (cont.)Bank / Institution: _______________________________________________________________________________________

Title (Names) on Account: ________________________________________________________________________

Contact Name: ________________________________ Phone: _________________

AccountNumber:___________________________ Type of Account: _________________________________

___________________________________________________________________________________

___________________________________________________________________________________

AccountNumber:___________________________ Type of Account: _________________________________

___________________________________________________________________________________

___________________________________________________________________________________

AccountNumber:___________________________ Type of Account: _________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Bank / Institution: _______________________________________________________________________________________

Title (Names) on Account: ________________________________________________________________________

Contact Name: ________________________________ Phone: _________________

AccountNumber:___________________________ Type of Account: _________________________________

___________________________________________________________________________________

___________________________________________________________________________________

AccountNumber:___________________________ Type of Account: _________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Additional related details or important information regarding these accounts:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

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____________________________

Name Trust Accounts/SecuritiesTRUST ACCOUNTS

Institution: ______________________________________________________ Type of Trust: ______________________________

Address: _______________________________________________________________________________________________________

Tax ID Number: ________-______-___________ Current Trustee(s): ________________________________________________

Successor Trustee: ____________________________________________________________________________________________

Beneficiaries: __________________________________________________________________________________________________

Notes: _________________________________________________________________________________________________________

Institution: ______________________________________________________ Type of Trust: ______________________________

Address: _______________________________________________________________________________________________________

Tax ID Number: ________-______-___________ Current Trustee(s): ________________________________________________

Successor Trustee: ____________________________________________________________________________________________

Beneficiaries: __________________________________________________________________________________________________

Notes: _________________________________________________________________________________________________________

SECURITIES

Brokerage Firm: _____________________________________ Account Number: _____________________________________

Title (Names) on Account: _______________________________________ Type of Account: ____________________________

Notes: _________________________________________________________________________________________________________

Brokerage Firm: _____________________________________ Account Number: _____________________________________

Title (Names) on Account: _______________________________________ Type of Account: ____________________________

Notes: _________________________________________________________________________________________________________

Additional related details or important information regarding these accounts:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

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____________________________

Name IRAs / Retirement AccountsType: __________________________________________________________________________________________________________

Participant: ___________________________________________________________________________________________________

Name of Company / Contact: _______________________________________ Phone: ( ) ___________-_____________

Address: ______________________________________________________________________________________________________

Account Number: ___________________________________ Approximate Value: $______________________________

Primary Beneficiaries: ____________________________________________________

Contingent Beneficiaries: __________________________________________________

Notes: ________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Type: __________________________________________________________________________________________________________

Participant: ___________________________________________________________________________________________________

Name of Company / Contact: _______________________________________ Phone: ( ) ___________-_____________

Address: ______________________________________________________________________________________________________

Account Number: ___________________________________ Approximate Value: $______________________________

Primary Beneficiaries: ____________________________________________________

Contingent Beneficiaries: __________________________________________________

Notes: ________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Additional related details or important information regarding these accounts:

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

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IRAs / Retirement Accounts(cont.)Type: __________________________________________________________________________________________________________

Participant: ___________________________________________________________________________________________________

Name of Company / Contact: ______________________________________ Phone: ( ) ___________-______________

Address: ______________________________________________________________________________________________________

Account Number: ___________________________________ Approximate Value: $______________________________

Primary Beneficiaries: ____________________________________________________

Contingent Beneficiaries: __________________________________________________

Notes: ________________________________________________________________________________________________________

Type: __________________________________________________________________________________________________________

Participant: ___________________________________________________________________________________________________

Name of Company / Contact: ______________________________________ Phone: ( ) ___________-______________

Address: ______________________________________________________________________________________________________

Account Number: ___________________________________ Approximate Value: $______________________________

Primary Beneficiaries: ____________________________________________________

Contingent Beneficiaries: __________________________________________________

Notes: ________________________________________________________________________________________________________

Additional related details or important information regarding these accounts:

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

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____________________________

Name IRAs / Retirement Accounts(cont.)Type: __________________________________________________________________________________________________________

Participant: ___________________________________________________________________________________________________

Name of Company / Contact: ______________________________________ Phone: ( ) ___________-______________

Address: ______________________________________________________________________________________________________

Account Number: ___________________________________ Approximate Value: $______________________________

Primary Beneficiaries: ____________________________________________________

Contingent Beneficiaries: __________________________________________________

Notes: ________________________________________________________________________________________________________

Type: __________________________________________________________________________________________________________

Participant: ___________________________________________________________________________________________________

Name of Company / Contact: ______________________________________ Phone: ( ) ___________-______________

Address: ______________________________________________________________________________________________________

Account Number: ___________________________________ Approximate Value: $______________________________

Primary Beneficiaries: ____________________________________________________

Contingent Beneficiaries: __________________________________________________

Notes: ________________________________________________________________________________________________________

Additional related details or important information regarding these accounts:

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

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IRAs / Retirement Accounts(cont.)Type: __________________________________________________________________________________________________________

Participant: ___________________________________________________________________________________________________

Name of Company / Contact: ______________________________________ Phone: ( ) ___________-______________

Address: ______________________________________________________________________________________________________

Account Number: ___________________________________ Approximate Value: $______________________________

Primary Beneficiaries: ____________________________________________________

Contingent Beneficiaries: __________________________________________________

Notes: ________________________________________________________________________________________________________

Type: __________________________________________________________________________________________________________

Participant: ___________________________________________________________________________________________________

Name of Company / Contact: ______________________________________ Phone: ( ) ___________-______________

Address: ______________________________________________________________________________________________________

Account Number: ___________________________________ Approximate Value: $______________________________

Primary Beneficiaries: ____________________________________________________

Contingent Beneficiaries: __________________________________________________

Notes: ________________________________________________________________________________________________________

Additional related details or important information regarding these accounts:

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

www.MemoryBanc.com

____________________________

Name Insurance PoliciesHOME / RENTAL

Owned by: _________________________________________________________ Type of Policy: ____________________________

Account Number: ___________________________ Issuer: _________________________________________________________

Contact: ____________________________________ Phone: ( ) ___________-_______________

Replacement Coverage: ______________________________________________________________________

Coverage Limits: ____________________________________________________________________________

Annual Premium: $______________ Annual Renewal Date: ______________ / ______________

LIFE

Covers: ________________________________________________________________________________________________________

Owned by: _________________________________________________________ Type of Policy: ____________________________

Account Number: ___________________________ Issuer: _________________________________________________________

Beneficiary: ___________________________________________________________________________________________________

Contact: ____________________________________ Phone: ( ) ___________-_______________

Death Benefit: $______________ Cash Value: $______________________

Annual Premium: $______________ Annual Renewal Date: ______________ / ______________

AUTO

Issuer / Contact: ____________________________________________________ Policy Number: ________________________

Address: __________________________________________________________ Phone: ( ) ___________-_______________

Drivers Insured: ___________________________________________________________________________________________

(1) Year / Make / Model: ______________________________________________ License Plate: ________________

(2) Year / Make / Model: ______________________________________________ License Plate: ________________

(3) Year / Make / Model: ______________________________________________ License Plate: ________________

Premium: $________________ (Monthly / Quarterly / Annually)

Renewal Date(s): __________________

(MM) (DD)

(MM) (DD)

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Other Investments / Asset DetailsANNUITIES

Owned By Account Type Issuer Beneficiary Death Benefit Cash Value

$ $

$ $

$ $

$ $

Additional related details or important information regarding these accounts:

_________________________________________________________________________________________________________________

REAL ESTATE OWNERSHIP

Location of Property: __________________________________________________________________________________________

Type of Ownership: Full / Partial Interest / Other: _____________________________________

Estimated Appraisal Value: $__________________ Related Paperwork Location: ________________________

Special Notes Related to Property: ____________________________________________________________________

Location of Property: __________________________________________________________________________________________

Type of Ownership: Full / Partial Interest / Other: _____________________________________

Estimated Appraisal Value: $__________________ Related Paperwork Location: ________________________

Special Notes Related to Property: ____________________________________________________________________

COLLECTIONS

Description: ___________________________________________________________________________________________________

Location of Collection: ________________________________________________________________________________

Inventory: _____________________________________________________________________________________________

Additional Details: ____________________________________________________________________________________

Description: ___________________________________________________________________________________________________

Location of Collection: ________________________________________________________________________________

Inventory: _____________________________________________________________________________________________

Additional Details: ____________________________________________________________________________________

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Monthly / Quarterly / Annual Income INCOME

Take-Home Pay, Retirement, Interest / Dividends, Alimony / Child Support, Investments, etc.

Income Source: _______________________________________________________________________________________________

Address: ______________________________________________________________________________________________

Contact Name: ____________________________________________ Phone: ( ) ___________-______________

Pay Cycle: ______________________________ Monthly Estimated Income (after taxes): $ _________________

Notes: ________________________________________________________________________________________________

Income Source: _______________________________________________________________________________________________

Address: ______________________________________________________________________________________________

Contact Name: ____________________________________________ Phone: ( ) ___________-______________

Pay Cycle: ______________________________ Monthly Estimated Income (after taxes): $ _________________

Notes: ________________________________________________________________________________________________

Income Source: _______________________________________________________________________________________________

Address: ______________________________________________________________________________________________

Contact Name: ____________________________________________ Phone: ( ) ___________-______________

Pay Cycle: ______________________________ Monthly Estimated Income (after taxes): $ _________________

Notes: ________________________________________________________________________________________________

Income Source: _______________________________________________________________________________________________

Address: ______________________________________________________________________________________________

Contact Name: ____________________________________________ Phone: ( ) ___________-______________

Pay Cycle: ______________________________ Monthly Estimated Income (after taxes): $ _________________

Notes: ________________________________________________________________________________________________

Additional related details or important information regarding these accounts:

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

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LoansHOUSING / PROPERTY / REAL ESTATE LOANS

Circle One: Own Rent Other: ___________________

Property Address: __________________________________________ Lender / Landlord: ______________________________

Lenders / Landlords Address: ________________________________________________________________________________

Account Number: _______________________ Loan Amount: $_________________

Monthly Payment Amount: $ ____________ Monthly Billing Due Date: __________________

Related Fees (Homeowner Association or Condominium Fees): $___________________________

Make Payments To: _______________________________________________________________

Address: __________________________________________________________________________

Phone: ( ) ___________-_______________

Circle One: Own Rent Other: ___________________

Property Address: __________________________________________ Lender / Landlord: ______________________________

Lenders / Landlords Address: ________________________________________________________________________________

Account Number: _______________________ Loan Amount: $_________________

Monthly Payment Amount: $ ____________ Monthly Billing Due Date: __________________

Related Fees (Homeowner Association or Condominium Fees): $___________________________

Make Payments To: _______________________________________________________________

Address: __________________________________________________________________________

Phone: ( ) ___________-_______________

Additional related details or important information regarding these accounts:

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

__________________________________________________________________________________________________

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____________________________

Name Loans(cont.)AUTOMOBILE LOANS

(1) Year / Make / Model: ________________________________ Location of Automobile: ____________________________

Lender: _____________________________________ Lenders Address: ____________________________________________

Account Number: ___________________________ Loan Amount: $__________________

Payment Amount: $_________________________ Monthly Billing Due Date: __________________

(2) Year / Make / Model: ________________________________ Location of Automobile: ____________________________

Lender: _____________________________________ Lenders Address: ____________________________________________

Account Number: ___________________________ Loan Amount: $__________________

Payment Amount: $_________________________ Monthly Billing Due Date: __________________

(3) Year / Make / Model: ________________________________ Location of Automobile: ____________________________

Lender: _____________________________________ Lenders Address: ____________________________________________

Account Number: ___________________________ Loan Amount: $__________________

Payment Amount: $_________________________ Monthly Billing Due Date: __________________

OTHER LOAN (not home or automobile loan): ____________________________________________________

Loan Description: ____________________________________________________________________________________________

Lender: _____________________________________ Lenders Address: ____________________________________________

Account Number: ___________________________ Loan Amount: $__________________

Payment Amount: $_________________________ Monthly Billing Due Date: __________________

OTHER LOAN (not home or automobile loan): ____________________________________________________

Loan Description: ____________________________________________________________________________________________

Lender: _____________________________________ Lenders Address: ____________________________________________

Account Number: ___________________________ Loan Amount: $__________________

Payment Amount: $_________________________ Monthly Billing Due Date: __________________

Additional related details or important information regarding these accounts:

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

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Credit Cards CREDIT CARDS (BANK AND RETAIL CARDS)

Card Name: ________________________________________ Card Number: __________________________________________

Exp. Date: ______/______/_________ Security Code: ____________________

Card Issuer Address: __________________________________________________________________________________

Phone: ( ) ___________-_______________ Monthly Billing Due Date: __________________

Account Website: ___________________ Pin: ________

Username: ________________________ Password: _______________________________

Card Name: ________________________________________ Card Number: __________________________________________

Exp. Date: ______/______/_________ Security Code: ____________________

Card Issuer Address: __________________________________________________________________________________

Phone: ( ) ___________-_______________ Monthly Billing Due Date: __________________

Account Website: ___________________ Pin: ________

Username: ________________________ Password: _______________________________

Card Name: ________________________________________ Card Number: __________________________________________

Exp. Date: ______/______/_________ Security Code: ____________________

Card Issuer Address: __________________________________________________________________________________

Phone: ( ) ___________-_______________ Monthly Billing Due Date: __________________

Account Website: ___________________ Pin: ________

Username: ________________________ Password: _______________________________

Card Name: ________________________________________ Card Number: __________________________________________

Exp. Date: ______/______/_________ Security Code: ____________________

Card Issuer Address: __________________________________________________________________________________

Phone: ( ) ___________-_______________ Monthly Billing Due Date: __________________

Account Website: ___________________ Pin: ________

Username: ________________________ Password: _______________________________

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____________________________

Name Credit Cards (cont.) Card Name: ________________________________________ Card Number: __________________________________________

Exp. Date: ______/______/_________ Security Code: ____________________

Card Issuer Address: __________________________________________________________________________________

Phone: ( ) ___________-_______________ Monthly Billing Due Date: __________________

Account Website: ___________________ Pin: ________

Username: ________________________ Password: _______________________________

Card Name: ________________________________________ Card Number: __________________________________________

Exp. Date: ______/______/_________ Security Code: ____________________

Card Issuer Address: __________________________________________________________________________________

Phone: ( ) ___________-_______________ Monthly Billing Due Date: __________________

Account Website: ___________________ Pin: ________

Username: ________________________ Password: _______________________________

Card Name: ________________________________________ Card Number: __________________________________________

Exp. Date: ______/______/_________ Security Code: ____________________

Card Issuer Address: __________________________________________________________________________________

Phone: ( ) ___________-_______________ Monthly Billing Due Date: __________________

Account Website: ___________________ Pin: ________

Username: ________________________ Password: _______________________________

Card Name: ________________________________________ Card Number: __________________________________________

Exp. Date: ______/______/_________ Security Code: ____________________

Card Issuer Address: __________________________________________________________________________________

Phone: ( ) ___________-_______________ Monthly Billing Due Date: __________________

Account Website: ___________________ Pin: ________

Username: ________________________ Password: _______________________________

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UtilitiesAccount Service Address: _____________________________________________________________________________________

ELECTRIC

Provider Name: ___________________________________________________ Phone: ( ) ___________-_______________

Provider Address: _____________________________________________________________________________________________

Account Holder: __________________________________________ Account Number: _________________________________

Billing Due Date: __________________ (Monthly / Quarterly / Annually)

Account Website: ____________________________________________________________________________

Username: _____________________________________ Pin: ________________________________________

Password: ______________________________________ Email: ______________________________________

GAS

Provider Name: ___________________________________________________ Phone: ( ) ___________-_______________

Provider Address: _____________________________________________________________________________________________

Account Holder: __________________________________________ Account Number: _________________________________

Billing Due Date: __________________ (Monthly / Quarterly / Annually)

Account Website: ____________________________________________________________________________

Username: _____________________________________ Pin: ________________________________________

Password: ______________________________________ Email: ______________________________________

WATER

Provider Name: ___________________________________________________ Phone: ( ) ___________-_______________

Provider Address: _____________________________________________________________________________________________

Account Holder: __________________________________________ Account Number: _________________________________

Billing Due Date: __________________ (Monthly / Quarterly / Annually)

Account Website: ____________________________________________________________________________

Username: _____________________________________ Pin: ________________________________________

Password: ______________________________________ Email: ______________________________________

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Utilities (cont.)Account Service Address: _____________________________________________________________________________________

SEWER

Provider Name: ___________________________________________________ Phone: ( ) ___________-_______________

Provider Address: _____________________________________________________________________________________________

Account Holder: __________________________________________ Account Number: _________________________________

Billing Due Date: __________________ (Monthly / Quarterly / Annually)

Account Website: ____________________________________________________________________________

Username: _____________________________________ Pin: ________________________________________

Password: ______________________________________ Email: ______________________________________

TRASH

Provider Name: ___________________________________________________ Phone: ( ) ___________-_______________

Provider Address: _____________________________________________________________________________________________

Account Holder: __________________________________________ Account Number: _________________________________

Billing Due Date: __________________ (Monthly / Quarterly / Annually)

Account Website: ____________________________________________________________________________

Username: _____________________________________ Pin: ________________________________________

Password: ______________________________________ Email: ______________________________________

PHONE (Home / Mobile)

Provider Name: ___________________________________________________ Phone: ( ) ___________-_______________

Provider Address: _____________________________________________________________________________________________

Account Holder: __________________________________________ Account Number: _________________________________

Billing Due Date: __________________ (Monthly / Quarterly / Annually)

Account Website: ____________________________________________________________________________

Username: _____________________________________ Pin: ________________________________________

Password: ______________________________________ Email: ______________________________________

www.MemoryBanc.com

Utilities (cont.)Account Service Address: _____________________________________________________________________________________

PHONE (Home / Mobile)

Provider Name: ___________________________________________________ Phone: ( ) ___________-_______________

Provider Address: _____________________________________________________________________________________________

Account Holder: __________________________________________ Account Number: _________________________________

Billing Due Date: __________________ (Monthly / Quarterly / Annually)

Account Website: ____________________________________________________________________________

Username: _____________________________________ Pin: ________________________________________

Password: ______________________________________ Email: ______________________________________

INTERNET / CABLE / DISH

Provider Name: ___________________________________________________ Phone: ( ) ___________-_______________

Provider Address: _____________________________________________________________________________________________

Account Holder: __________________________________________ Account Number: _________________________________

Billing Due Date: __________________ (Monthly / Quarterly / Annually)

Account Website: ____________________________________________________________________________

Username: _____________________________________ Pin: ________________________________________

Password: ______________________________________ Email: ______________________________________

OTHER

Provider Name: ___________________________________________________ Phone: ( ) ___________-_______________

Provider Address: _____________________________________________________________________________________________

Account Holder: __________________________________________ Account Number: _________________________________

Billing Due Date: __________________ (Monthly / Quarterly / Annually)

Account Website: ____________________________________________________________________________

Username: _____________________________________ Pin: ________________________________________

Password: ______________________________________ Email: ______________________________________

www.MemoryBanc.com

Utilities (cont.)Account Service Address: _____________________________________________________________________________________

OTHER

Provider Name: ___________________________________________________ Phone: ( ) ___________-_______________

Provider Address: _____________________________________________________________________________________________

Account Holder: __________________________________________ Account Number: _________________________________

Billing Due Date: __________________ (Monthly / Quarterly / Annually)

Account Website: ____________________________________________________________________________

Username: _____________________________________ Pin: ________________________________________

Password: ______________________________________ Email: ______________________________________

OTHER:

Provider Name: ___________________________________________________ Phone: ( ) ___________-_______________

Provider Address: _____________________________________________________________________________________________

Account Holder: __________________________________________ Account Number: _________________________________

Billing Due Date: __________________ (Monthly / Quarterly / Annually)

Account Website: ____________________________________________________________________________

Username: _____________________________________ Pin: ________________________________________

Password: ______________________________________ Email: ______________________________________

OTHER:

Provider Name: ___________________________________________________ Phone: ( ) ___________-_______________

Provider Address: _____________________________________________________________________________________________

Account Holder: __________________________________________ Account Number: _________________________________

Billing Due Date: __________________ (Monthly / Quarterly / Annually)

Account Website: ____________________________________________________________________________

Username: _____________________________________ Pin: ________________________________________

Password: ______________________________________ Email: ______________________________________

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