Date

 

TO WHOM IT MAY CONCERN:

 

INFORMATION CONCERNING MYSELF AND RELATIVES:

 

          NAME           BIRTH DATE     ADDRESS

 

     Include self, immediate family, including parents and

     in-laws, living or not (with date and place of death)

 

LOCATION OF IMPORTANT ITEMS:

 

SAFE DEPOSIT BOX, STORAGE UNITS (location and number; where keys are)                            

 

WILLS & TRUST DOCUMENT -

 

LIVING WILL - (if any)

 

TRUST & TRUSTEES - (details, name and date of, and location of document)

 

CHARITABLE REMAINDER TRUSTS (if any) - full details

 

BIRTH CERTIFICATES -

 

NATURALIZATION PAPERS -

 

ADOPTION PAPERS -

 

PASSPORTS - (numbers and date and location of issue)

 

MARRIAGE LICENSE, PRE OR POST-NUPTUAL AGREEMENT (or Domestic Partnership

                                 Registration --local, state or business)

 

DIVORCE PAPERS -

 

VETERANS DISCHARGE -

 

STOCKS -

 

TITLE POLICY, DEED OF TRUST, AND COUNTY RECORDING ON HOME -

 

CERTIFICATES OF OWNER ON CARS -

 

COPY OF ............... DISCHARGE PAPER FROM WORLD WAR I (for LaVerne

             Noyes Scholarship; see further information to come below) -

    

DEED FOR CEMETERY LOT - (details about lot and location of Deed and/or

                         about Burial Society etc.)

 

FIRE INSURANCE POLICY - (who with and location of policy

 

 

COIN COLLECTION, ART COLLECTION, JEWELRY COLLECTION, etc. -

 

INTERNET LOGINS & PASSWORDS - 

 

INSURANCE POLICIES -

 

     (Company name, policy number, kind of policy and on

     whose life)(Be sure to update beneficiary designations)

 

     (Don't forget policies at work including the following:

 

          Travel Insurance - thru credit card to which tickets are charged

         

          Executive Travel Insurance - thru UCLA

 

          State of California - thru work at UCLA

 

(See UC Benefits Counselor for details on all coverages)

 

Accidental Death & Dismemberment Insurance for $...... each provided by
     ........ bank & the ....... credit union.

    

IMPORTANT NUMBERS:

 

     .................. Social Security #

 

     (list for each living family member)

 

     .................. Veterans Administration C-Number

 

INCOME TAX PAPERS and significant tax records -

 

BUSINESS RECORDS -

 

CHECKING ACCOUNTS:

 

     (name of bank, location, and account number for each)

 

IRA'S - (name, address and telephone number of Bank, account numbers,

           maturities, and location of paperwork)

 

MONEY MARKET FUND ACCOUNT:

 

     (name of bank, location, account number and location of paperwork)

    

SAVINGS ACCOUNTS:  (same as above)

 

SECURITIES BROKERS:

 

     (firm name, agent, account number, with address and telephone number)

    

BONDS:

 

     Bonds registered in the name of ...... or held by ........, in street

     name.  Transaction receipts and quarterly statements ......... Bonds

     in .............. or held by ......................

 

AIRLINE MILEAGE ACCOUNTS:  (could have free trips available to members of

     family or friends, as long as they are not sold)

    

HOME LOAN from .............. Loan papers in ...........(Loan # ........)

 

OTHER LOANS (full details)

 

LIST PAYMENTS WHICH ARE MADE AUTOMATICALLY EACH MONTH ETC.

 

OTHER IMPORTANT FINANCIAL INFORMATION:

 

PUBLIC EMPLOYEES' RETIREMENT SYSTEM: .......... entitled to retirement

     benefits payable on a monthly basis. (See Benefits Program Counselor

     at UCLA for details on all benefits available.)  Yearly statement of

     contributions located in ........ (........ contributions when repaid
     are tax free; taxes have already been paid on this amount only.) 
     Additional service credit would be given for unused sick leave.

 

UCLA DEATH BENEFITS: See Benefits Program Counselor at UCLA for details.

     (Starting date of employment was .......)

 

REGULAR AND/OR OPTIONAL TAX DEFERRED RETIREMENT PROGRAM

     through the University of California Retirement System begun (date).

     (Quarterly statements of contributions located in ..........)  See

     Benefits Program Counselor at UCLA for details and options.  (Do not

     take an annuity--leave on deposit, take interest needed only, or

     withdrawals as required as of 70 1/2 years of age.  If large balance,

     plan withdrawals earlier than 70 1/2)

 

STATE SURVIVOR'S BENEFITS: (See Benefits Program Counselor at UCLA for

     details.)

 

VETERANS ADMINISTRATION: $250 (or perhaps more now) towards burial and

     American flag!  Check with V.A. to see if other benefits are

     available (See "C#" given above).

 

SOCIAL SECURITY: Presently FULLY covered, but probably qualify for only

     small benefits.  Check with Social Security regarding exact benefits.

     Do not forget to add time of military service when claiming benefits.

    

Check with CAL VET for possible benefits.  (Benefit number is .......)

     Certificate of Eligibility is located in .................

 

 

    

All descendants of (a person who served in WW I) are entitled to LaVerne

     Noyes Scholarships to help pay for college education.  Need copy of

     discharge paper referred to above.  Apply directly to the College or

     University involved.  There may be a "needs" test.

 

In case of work related death or accident, check benefits derived from

     California State Fund Insurance coverage, thru the University

     directly (Executive Travel coverage), and thru credit card company

     if travel costs were charged.

    

In case of death, notify: doctor(s); attorney; Social Security; employer

(Campus Emeriti Ctr & OP Survivor Unit); insurance agent; relatives & friends; clubs & organizations; clergyman; funeral/cemetery director(s).

 

Information on the disposition of pets.

 

Family belongs to ...... Health Plan through UCLA (Family account # ....)

     Check with UCLA Benefits Program Counselor regarding coverage and ability to retain coverage for the family in one of the available

     health plans.  Some retirement benefits must be forthcoming monthly     in order to cover part of the payment.  Check carefully before    determining what to do with voluntary retirement plan proceeds.

 

Family is covered under a Dental Plan at UCLA.  (Check with Benefits

     Program Counselor regarding details for continuation of benefits.)      Dental records with Dr. ..........,DDS, (address).

 

Also covered for Vision Care (Check with Benefits Program Counselor     regarding details for continuation of benefits, if available--may not be).

 

Auto & Home Insurance Agent:   (name, address, and phone number)

 

Life Insurance Agent:  (same as above)

 

Tax &/or other Attorney:  (same as above)

 

For advice: See  (same as above)

 

                                    (signed)

 

Prepared by: Adrian H. Harris, UCLA, (310) 825-2244

E-mail: harris@ucla.edu

 

SHOULD BE UPDATED WHENEVER A CHANGE OCCURS OR AT LEAST EVERY SIX MONTHS.

 

Original document: 1965; Current version: 9-1-2007