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Organization Financial Affairs This quick and simple form organizes the information necessary to assist your loved one at a moment’s notice, such as banking and investment information. Ask your loved one to complete one for themselves. You can also complete one for yourself and give it to someone you trust. You may also want to consider speaking with your accountant for professional guidance, if you are considering adding yourself to your loved one’s accounts. It is also important to address some of these issues, if possible, prior to your loved one losing the capacity to give consent. If you notice that your loved one is beginning to have some memory impairment, it is a good idea to begin assisting them with their bills and banking and get this process started. 1. Sources of income:
Additional information
A
Amount
TH
IS
IS
Location (RIF, IRA, pension, 401’k, etc.)
2. Valuables (art, jewelry, etc. and their estimated values, insurance on item, etc.): ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST ©2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without prior written permission.
3. Current professional contact information Name
Notary Attorney Financial advisor Stockbroker
Phone
A
Insurance agent
Address
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Professional Accountant
IS
4. Banking Power of Attorney: Your bank/financial institution may have a specific form they need completed for another person to have financial power of attorney. Account #
Contact
Phone number
Address
TH
IS
Institution
Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST Š2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without prior written permission.
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5. Power of Attorney/Mandate/Durable Power of Attorney – intended for use when parent is incapacitated Prepared by: ______________________________________________ Phone number: ____________________________________________ Address: _________________________________________________ Date: ____________________________________________________ Location of original: _________________________________________ People who also have copies: (this should include your loved one’s primary physician and all people who are designated agents) ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Other: ____________________________________________________
IS
IS
A
6. Will: You should obtain a copy and put it in a safe place. a. Drafted by (name, address, phone): _____________________________________________________ _____________________________________________________ b. Drafted on date: ________________________________________ c. Location of original: _____________________________________ d. Executor contact information (name, address, phone) i. ________________________________________________ ________________________________________________ ii. ________________________________________________ ________________________________________________ iii. ________________________________________________ ________________________________________________
TH
7. Trust agreements: You should obtain a copy and put it in a safe place. a. Drafted by (name, address, phone): _____________________________________________________ _____________________________________________________ b. Drafted on date: ________________________________________ c. Location of original: _____________________________________ d. Other important details: _____________________________________________________ _____________________________________________________ _____________________________________________________
Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST ©2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without prior written permission.
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8. Location of most recent tax return: ___________________________________________________________ Accountant contact information: ___________________________________________________________ ___________________________________________________________ 9. Bank accounts:
Account # Contact Checking or Savings
Phone number
Address
Pin number
TH
IS
IS
A
Institution
Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST Š2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without prior written permission.
10. Retirement, investments, pension: Address
Contact
Phone
DE M O
Account #
IS
A
Institution
11. Day to Day finances:
Amount
Account #
Phone number
IS
Institution, provider, contact
Mortgage
TH
Home insurance Rent
Phone
Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST Š2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without prior written permission.
Water
Gas
Cell phone
Car
Car Insurance
Account #
Phone number
A
Electric
Amount
DE M O
Institution, provider, contact
Taxes
IS
Taxes
IS
Taxes
TH
Taxes
Credit card
Credit card
Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST ©2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without prior written permission.
Institution, provider, contact
Account #
Phone number
12. Liabilities
To whom
For what
Payment details
TH
IS
IS
Money owed
A
DE M O
Loans
Amount
Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST Š2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without prior written permission.
13. On-line banking or other information
Email used
Account
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Computer sign on: User name: _____________________ password: __________________ Password
Additional instructions:
TH
IS
IS
A
14. Other notes or additional instructions: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST Š2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without prior written permission.