Name _________________________________________________________________________________
(Last) (First) (Middle)

Social Security Number____________________________ Date of Birth  ________________________

Place of Birth __________________________________________________________________________
(City) (County) (State) (Country)

Father's Name __________________________________________________________________________
(Last) (First) (Middle)

Mother's Name _________________________________________________________________________
(Last) (First) (Middle)

Service ________________ Retired Grade/Rank___________ Date of Retirement_________________
(DD Form 214)

Receiving VA Disability? Yes/No ____ Percentage __________ VA Claim Number_________________

Enrolled in Survivor Benefit Plan SBP/SSBP, Retired Serviceman's Family Protection Plan RSFPP,
Civil Service, etc.? ______________________________________________________________________
(Indicate which program, if any)

Receiving Social Security? Yes/No _____ If yes, age & date at which first received________________

Is there a Living Will or Trust? Yes/ No_____ If yes, location__________________________________

Spouse ________________________________________________________________________________
(Last) (First) (Middle) (SSN)

Spouse Date of Birth _____________Date of Marriage________Place of Marriage_________________

Children
Name Address Date of Birth Capable of Self Support

______________________________________________________________________________________

______________________________________________________________________________________

(Add additional pages as necessary)
Burial Information
Persons to be notified of your death (Other than spouse)

Name Relationship Address Telephone Number

________________________________________________________________________________________________

_______________________________________________________________________________________________

Do you have a preference of funeral home? Yes/No _________ If yes, location ____________________

Have you purchased a burial plot? Yes/ No ______ If yes, location ______________________________
Do you want to be buried/cremated? (Indicate which one)_____________________________________

Name and location of cemetery where you want to be buried ___________________________________

Do you want to be buried/cremated in your uniform? Yes/No _______ If yes, location________________

Do you want a military honor guard? Yes/No _______ Other special request ______________________

Insurance Information

Policy Number Company Amount Beneficiary Agent Phone Number

_______________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Bank Accounts

Bank Name Account Number Type of Account (Checking/Savings) Amount

_______________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Investment Information

Type (Stock, CD, IRA, Mutual, etc) Company/ Broker Amount Agent Phone Number

________________________________________________________________________________________________

________________________________________________________________________________________________

_______________________________________________________________________________________________

Creditor Information

Name Address Account Number Type Account Balance
________________________________________________________________________________________________

________________________________________________________________________________________________