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
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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 [email protected].
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? __________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
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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? __________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
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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:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
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____________________________
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: ______________________________________
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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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