PERSONAL AND FINANCIAL INFORMATION

Bank Accounts:

Checking Bank: ___ Account #: ___

Address: _____ Earns Interest/Amount: _____

Savings Bank: ___ Account #: ___

Address: _____ Earns Interest/Amount: _____

Benefits:

SS#: _____-___-___ SSI Claim #: ___

SSDI Claim #: ___ Other Claim #'s: ___

Medicare #: ___ Is Premium Deducted from SSDI: ☐ Yes ☐ No

Medicaid #: ___ Spend down: ☐ Yes ☐ No Amount: ___

Redetermination Date: ___ Medicaid Recipient #: ___

Other Benefit/Assistance: ___

Insurance:

Burial Reserve: ☐ Yes ☐ No Amount: ___ Contract #: ___

Name of Funeral Home/Address: ___

Life Insurance Policy: ☐ Yes ☐ No Company: ___ Policy #: ___

Policy Amount: ___ Face Value: ___ Cash In Value: ___

Policy Owner: ___ Name of Insured: ___

Beneficiary: _____ Location of Policy: _____

Other Insurance Company: ___ Policy #: ___

Type of Coverage: ___ Amount: ___

Real Estate/Property Assets:

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