living ledger · web viewtask force, the revision task force spent considerable time in discussing,...

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© 2007 UW-Madison Retirement Association, Original 2007, Revised January 2019 of 49

LIVING LEDGERA Compilation of Vital Personal Information

For _____________________________________________________________

Date Completed __________________________________________________

© UW-Madison Retirement AssociationOriginal 2007 Revision 2019

Date Revised ____________________

DISCLAIMERLIVING LEDGER was created solely for use as a tool for identifying and locating personal documents that executors and agents with power of attorney will need when carrying out the wishes of UW-Madison Retirement Association members with respect to their financial resources, real or virtual property, and end-of-life issues. LIVING LEDGER should not be construed as giving legal or financial advice. It cannot serve as a substitute for legal or financial advisers.

Although it is copyrighted material, it is available to UWRA members for personal use. It may be copied without seeking permission but may not be reproduced for commercial sale or sold at more than reproduction cost. If copies are made, the UW-Madison Retirement Association must be identified as the source.

UW-Madison Retirement Associationc/o Division of Continuing Studies21 North Park Street, Room 7205

Madison, WI 53715-1218

[email protected]


Date Revised ____________________

Table of ContentsSECTION I -- INTRODUCTION...................................................................................................................................... 6

SECTION II -- GETTING STARTED................................................................................................................................. 7

SECTION III -- CAUTIONARY STATEMENT.................................................................................................................... 8

SECTION IV -- CONTACT INFORMATION...................................................................................................................... 9

A. AN OVERVIEW........................................................................................................................................................9B. PERSONAL INFORMATION......................................................................................................................................9C. VETERANS INFORMATION....................................................................................................................................10D. SPOUSE/PARTNER................................................................................................................................................10E. FORMER SPOUSE/PARTNER..................................................................................................................................11F. CHILDREN, GRANDCHILDREN, OTHER INDIVIDUALS TO BE CONTACTED..............................................................11G. EMERGENCY CONTACT PERSON(S) NAME/RELATIONSHIP...................................................................................12H. POWERS OF ATTORNEY........................................................................................................................................12

1. Financial Power of Attorney (POA) Information................................................................................................122. Power of Attorney for Health Care (POA-Health Care) Information..................................................................13

I. HEALTH INSURANCE.............................................................................................................................................141. Medicare Health Insurance...............................................................................................................................142. Prescription Drug Plan, Part D..........................................................................................................................143. Health Care Insurance Plan...............................................................................................................................15

J. DENTAL INSURANCE.............................................................................................................................................15K. OTHER MEDICAL INSURANCE...............................................................................................................................16L. MEDICAL CONTACTS.............................................................................................................................................16

1. Primary Care Physician Information.................................................................................................................162. Specialist Physician Information.......................................................................................................................163. Hospital Preferences.........................................................................................................................................16

M. OTHER INSURANCE...........................................................................................................................................171. Life Insurance....................................................................................................................................................172. Disability Insurance Policy................................................................................................................................173. Accidental Death Insurance Policy....................................................................................................................184. Long-Term Care Insurance Policy......................................................................................................................185. Home Insurance................................................................................................................................................196. Auto Insurance..................................................................................................................................................197. Other Insurance................................................................................................................................................19

N. APPOINTED AND LEGAL CONTACTS......................................................................................................................191. Personal Representative...................................................................................................................................192. Testamentary Trustee/Successor Trustees Information (Irrevocable Trust)......................................................203. Testamentary Trustee/Successor Trustees Information (Revocable Trust).......................................................204. Attorney Information........................................................................................................................................21

O. FAITH CONTACTS..................................................................................................................................................21P. BANK, CREDIT UNION AND OTHER FINANCIAL CONTACTS...................................................................................21

1. Bank and Credit Union......................................................................................................................................212. Virtual Bank (Also known as branchless or Internet-only bank)........................................................................223. Accountant.......................................................................................................................................................224. Financial Planning............................................................................................................................................22


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5. Brokerage (For investment and pre-tax accounts – 403(b) plans)....................................................................22Q. ORGANIZATIONS TO CONTACT UPON INCAPACITY, DISABILITY, OR DEATH.........................................................23

1. Wisconsin Department of Employee Trust Funds -- Retirees.............................................................................232. UW-Madison, Office of Human Resources – Current UW Employees...............................................................233. Social Security Administration..........................................................................................................................23

R. OTHER ORGANIZATIONS TO CONTACT.................................................................................................................23

SECTION V -- LOCATION OF DOCUMENTS................................................................................................................. 24

A. AN OVERVIEW......................................................................................................................................................24B. WHERE ARE YOUR PERSONAL DOCUMENTS KEPT?..............................................................................................24C. WHERE ARE YOUR LEGAL DOCUMENTS KEPT?.....................................................................................................25D. WHERE ARE YOUR BANK AND CREDIT UNION DOCUMENTS KEPT?.....................................................................25E. WHERE IS YOUR SAFE DEPOSIT BOX?...................................................................................................................25F. WHERE ARE YOUR INVESTMENT DOCUMENTS KEPT?..........................................................................................25G. WHERE ARE YOUR REAL ESTATE AND AUTOMOBILE DOCUMENTS KEPT?...........................................................26H. WHERE ARE YOUR INSURANCE DOCUMENTS KEPT?............................................................................................26I. WHERE ARE YOUR WISCONSIN EMPLOYEE TRUST FUNDS (ETF) DOCUMENTS KEPT?..........................................26J. WHERE ARE YOUR INCOME TAX DOCUMENTS KEPT?..........................................................................................27K. WHERE ARE YOUR OTHER FINANCIAL DOCUMENTS KEPT?..................................................................................27L. WHERE ARE YOUR PERSONAL DIGITAL PROPERTY DOCUMENTS KEPT?...............................................................27

1. Wills and Trusts................................................................................................................................................272. Power of Attorney - Finance.............................................................................................................................283. Terms of Digital Service Agreements................................................................................................................284. Digital Password Management Programs........................................................................................................285. Other Types of Personal Digital Properties.......................................................................................................28

SECTION VI -- FINANCIAL ASSET DOCUMENTATION..................................................................................................28

A. AN OVERVIEW......................................................................................................................................................28B. BANK AND CREDIT UNION ACCOUNTS.................................................................................................................29C. WISCONSIN EMPLOYEE TRUST FUNDS (ETF) RETIREMENT PLANS........................................................................30

1. Pension (See Section IV. P.1. for detailed contact information)........................................................................302. Tax-Sheltered Annuity – Also known as 403(b) plans.......................................................................................303. Deferred Compensation 457.............................................................................................................................304. Other (e.g., Roth)..............................................................................................................................................31

D. OTHER RETIREMENT PLANS..................................................................................................................................311. IRA (401K).........................................................................................................................................................312. Other Plans (529 College Plans, e.g., Edvest)....................................................................................................313. Other Plans.......................................................................................................................................................32

E. MANAGED INVESTMENT ACCOUNTS....................................................................................................................32F. INVESTMENT ACCOUNTS (STOCKS AND PARTNERSHIPS).....................................................................................33G. BOND PORTFOLIO INVESTMENT INFORMATION..................................................................................................33H. MUTUAL FUND INVESTMENT INFORMATION.......................................................................................................34I. REAL ESTATE – HOMESTEAD AND OTHER REAL ESTATE INFORMATION...............................................................35J. NOTE(S) AND LOAN(S) PAYABLE INFORMATION (MONEY YOU OWE - DEBT)............................................................36K. IMMEDIATE TAX DEFERRED OR VARIABLE ANNUITIES INFORMATION.................................................................36L. BUSINESS AND PARTNERSHIPS INFORMATION.....................................................................................................37M. TANGIBLE ASSET INFORMATION......................................................................................................................37

1. Automobiles, Boats, Planes, etc........................................................................................................................372. Jewelry, Art, Rare Books, Collectibles, Musical Instruments, etc.......................................................................38


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N. CREDIT AND DEBIT CARD INFORMATION.............................................................................................................39O. OTHER PROPERTY INFORMATION........................................................................................................................40P. WILL INFORMATION.............................................................................................................................................40Q. REVOCABLE TRUST INFORMATION.......................................................................................................................41R. IRREVOCABLE TRUST INFORMATION....................................................................................................................41

SECTION VII -- HEALTH CARE DOCUMENTATION....................................................................................................... 42

A. AN OVERVIEW......................................................................................................................................................42B. ADVANCE DIRECTIVES AND MEDICAL AUTHORIZATIONS.....................................................................................43

1. Power of Attorney for Health Care (POA-Health Care)......................................................................................432. Declaration to Physicians, also known as Living Will........................................................................................443. Physician Orders for Life-Sustaining Treatment (POLST)...................................................................................444. Do Not Resuscitate Order (DNR) and Bracelet..................................................................................................445. Authorization for Sharing of Medical Information............................................................................................45

C. YOUR HEALTH CARE AND MEDICAL RECORD INFORMATION AND LOCATION......................................................461. Advance Directive and Medical Authorization Information..............................................................................462. Medical Information.........................................................................................................................................46

SECTION VIII -- ORGAN, TISSUE, AND BODY DONATIONS..........................................................................................47

A. ORGAN AND TISSUE DONATIONS.........................................................................................................................47B. BODY DONATIONS................................................................................................................................................47

SECTION IX -- FUNERAL AND MEMORIAL INSTRUCTIONS..........................................................................................48

A. GUIDELINES FOR FUNERAL OR MEMORIAL SERVICES...........................................................................................481. Contact Upon Death.........................................................................................................................................482. Memorial Considerations..................................................................................................................................483. Prepaid/Prearranged Funeral Plans..................................................................................................................494. Considerations If Not Expressed in a Prepaid Plan............................................................................................49

B. GUIDELINES FOR FINAL ARRANGEMENTS.............................................................................................................49C. DEATH CERTIFICATE..............................................................................................................................................50

SECTION X -- OTHER INFORMATION THAT MAY BE IMPORTANT...............................................................................50


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SECTION I -- INTRODUCTIONFrom its inaugural year in 1999, the UW-Madison Retirement Association pledged that one of its priority concerns would be service to its members. Since then, numerous volunteers, both retired and active, some from the UW and some from the Madison community, have offered their time and expertise to the Association’s committees, which in turn have developed useful informational and social programs for the membership at large.

In this spirit, the Retirement Association set up a task force in 2007 to produce a manual LIVING LEDGER that members could use to organize their financial lives. The manual produced by this task force was intended to address the needs and benefit structures specific to UW retirees. The manual provided detailed forms in which users could record information concerning their financial life. The members of that extraor dinary task force were the following:

John W. Chandler, Vice Chair Faisal A. Kaud, Chair Steven R. SaffianLana R. M. Chandler Peter L. Monkmeyer Ann Wallace

Joe Corry Edna E. Paske June M. Weisberger

In 2017 the Committee on Financial Matters in Retirement reviewed the LIVING LEDGER and identified many places in which the document needed revision. After its careful examination of the older document, the CFMR decided that the LIVING LEDGER should be updated rather than laid to rest. Consequently, it assembled a new task force to do the updating. This document is the result of that revision.

Like the original LIVING LEDGER task force, the revision task force spent considerable time in discussing, compiling, and editing this manual. While doing that work, the members of the revision task force learned much of importance to their own individual situations. They hope that Retirement Association members will also find this manual to be of great practical benefit. The members of the revision task force were the following:

Faisal A. Kaud, Chair Karen Holden Gerald KulcinskiSandi Haase Millard Susman

The Task Force is also grateful to Betty Harris Custer, Howard Erlanger, Karen Goebel, June Weisberger Blanchard, Arden Trine, MaryBeth Plane, Bob Gurda, and Ann Wallace who reviewed the draft and made valuable suggestions.

As did the original, the revision includes forms to record financial information important for your own record organizing as well as for your financial and health agents and executors who must access those records. It also includes references from which users could obtain information concerning investment, estate planning, insurance, health care, and the multitude of financial issues that arise in our lives. We realize, of course, that the revised document will still be imperfect, and we invite you to let us know when you find omissions or errors.


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SECTION II -- GETTING STARTEDPersonal records are a source of comfort to some but a mystery to many. Wherever you find yourself on this continuum, you will have many friends and colleagues. The University of Wisconsin-Madison Retirement Association offers LIVING LEDGER to help you organize your critical personal and financial information in one place and in an efficient and accessible manner.

LIVING LEDGER provides a set of forms on which University of Wisconsin faculty, academic staff, and univer-sity (classified) staff (active and retired), as well as their spouses or partners and families, can record financial data, health status, health and personal advisers, and other essential information, as well as instructions to survivors in the event of death. We are confident that time spent in completing the forms of LIVING LEDGER will relieve anxieties and help build a more relaxed and enjoyable retirement.

When filling out the forms of LIVING LEDGER, we suggest the following:

Use LIVING LEDGER as an educational tool as well as a record. You will want to review all the pages to become familiar with the organization of LIVING LEDGER. Carefully consider whether each item applies to you or your spouse, partner, and family and your circumstances. Also, consider each item a prompt to your thought process. If you find items that are not yet part of your planning, you may want to give them further consideration or consult a professional adviser.

We suggest that you maintain digital copies of LIVING LEDGER, one on your computer and one at a secure backup location. You should diligently update them as changes occur in your investments or insurance arrangements. Whenever you make revisions, you might want to provide print or digital copies to your attorney, your financial adviser, and your personal representative, and POA agent.

Before completing an item, gather your relevant information, including any notes. If the information is up to date and applicable, complete the item. If not, move on to the next item.

You can certainly complete the forms of LIVING LEDGER in whatever order suits you. Remember that financial matters will require written documentation concerning your wishes. Your wishes concerning health care should be documented, but it is also important for you to discuss your preferences with family members and to make sure that they are committed to carrying out your wishes.

If your circumstances and those of your spouse or partner are sufficiently different, you will want to fill out two separate copies of LIVING LEDGER. If most of the entries are identical, however, a single LIVING LEDGER can be prepared by a couple. We suggest then that, for those areas of difference, appropriate pages be duplicated for the spouse or partner. In deciding between one or two copies of LIVING LEDGER, consideration should be given to the complexity of the revisions that will be needed on the death of either spouse or partner.

In completing the forms of LIVING LEDGER, you may want to seek advice from your attorney, accountant, financial adviser, or health care provider.

To record changes in your family, circumstances or financial situation, the LIVING LEDGER should be reviewed and updated at least once a year. Interim notations and revisions on a print copy should be dated in the upper right-hand corner under “Date Revised”. It is acceptable to cross out, rewrite, date,


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and initial items so as they can be read clearly. If you make changes in the digital version of the LIVING LEDGER with “track changes” turned on, the alterations will automatically be dated, and the owner of the computer making the changes will be recorded.

Insert additional pages as needed.

LIVING LEDGER is designed as a guide to organizing, recording, and passing on to others your personal and financial information. Your own circumstances may require eliminating, adding, or more fully explaining what is in this document. Provided as a WORD document, it allows you to edit and store the LEDGER on line. A printed document can have sections crossed out or pages and documents inserted. Please take this as your working document.

A completed LIVING LEDGER is likely to contain sensitive information that can compromise your identity, e.g., social security numbers and account numbers. Therefore, this information must be secured. Pass-words, PIN numbers, and other access codes should be recorded apart from LIVING LEDGER. The Internet has also introduced new record-keeping challenges as we store information on sites that require passwords and, often, answers to (personal) security questions. Passwords often must frequently be changed, for security reasons

The challenge of many and often-changed passwords may be managed by password management pro-grams that give access to your entire battery of passwords yet require you to remember only the pass -word to that management program. It is still necessary to enable your power of attorney or executor to access digital records. We recommend you explore management password options for your own security and discuss both with financial advisers and estate lawyer how your digital accounts can be accessed with your prior permission.

A useful website on the intersection between planning for a person’s incapacity and death and the digital world is www.digitalpassing.com. We also refer you to a December 2017 UWRA presentation on “Identity Theft and Data Breach Awareness“ at https://uwramadison.org/Presentations-(2017-2018) .

The copy of LIVING LEDGER that you keep at home may be used for quick reference and interim updates. The copy (paper or stored on a digital device) in the safe deposit box is a backup copy in case the working copy is destroyed or lost. The copy you give to your designated agent or emergency contact is for use in case you are not able to act on your own behalf. All copies should be reconciled once a year, perhaps when you do your annual tax preparation.

SECTION III -- CAUTIONARY STATEMENTPlease be aware of the following:

This set of materials is not legal advice. It is intended to help you, your appointed agents, and your survivors decide what and when professional advice is needed. It is also designed to provide help in understanding that advice, and it points out some available options, resources, and steps that may or must be taken. When seeking professional advice, it will be useful to bring this set of materials. It will save time and, possibly, money.

Since January 1986, when Wisconsin became a marital (community) property state, the rules determining property ownership by married couples have been dramatically different from those in “common law”


https://uwramadison.org/Presentations-(2017-2018)

http://www.digitalpassing.com/

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states. In a community property state, property ownership is not determined by which spouse’s name appears on the document of title. All property of married Wisconsin couples is presumed to be marital property and, accordingly, owned equally by both spouses. The marital property presumption may be rebutted, but excellent records must be available to establish a different property classification for an asset. Any questions or concerns should be discussed with an attorney familiar with Wisconsin’s Marital Property Law.

Spouses (or a couple about to marry) may sign a marital property agreement changing the marital property rules that would otherwise apply to their assets and, therefore, simplifying ownership determinations. Marital property agreements are frequently recommended for situations where not all a deceased spouse’s property is left to the surviving spouse for various reasons, including the desire to provide for a child or children from a previous marriage. Marital property agreements may also be helpful to implement some tax strategies. They may not be recognized, however, in determining eligibility for some public benefits and may only adversely affect creditors who have been given prior notice of the agreement. Given the complexities of marital property rules, including those governing marital property agreements, a knowledgeable profes -sional should be consulted to answer questions you may have.

Professional advice should be sought for interpretation and application of current law to individual circumstances as well as for relevant changes in the law that are likely to occur in the future. Also note, that addresses, websites, telephone numbers, and named individuals listed in LIVING LEDGER may also change over time.

SECTION IV -- CONTACT INFORMATIONA.AN OVERVIEW

This section documents personal information in a detailed manner so that it can be helpful in case of a life-changing situation. This includes documentation of insurance for health, life, real estate and automobiles; legal documents on wills, trusts, powers of attorney and property titling; financial documents on investments, brokers, banks, credit unions and retirement plans; and income tax filings.

B.PERSONAL INFORMATION MEMBER NAME SOCIAL SECURITY NUMBER

DATE OF BIRTH PLACE OF BIRTH (City, State, Country)

PRIMARY RESIDENCE ADDRESS (Street, City, State, Zip) STATE OF RESIDENCE

SECONDARY RESIDENCE ADDRESS (Street, City, State, Zip)

CITIZENSHIP (USA, Other) EMAIL

HOME PHONE CELL PHONE WORK PHONE

EMPLOYER TELEPHONE

ADDRESS

PASSWORDS LOCATIONCURRENT SPOUSE/PARTNER’S NAME, DATE, CITY, STATE, COUNTRY OF CURRENT MARRIAGE


Date Revised ____________________

FATHER’S NAME LIVING? BIRTHPLACE ____Yes ____ No

DATE OF BIRTH DATE OF DEATH

MOTHER’S FIRST AND MAIDEN NAME LIVING? BIRTHPLACE ____Yes ____ No

DATE OF BIRTH DATE OF DEATH

C.VETERANS INFORMATION BRANCH OF SERVICE RANK AND RATE AT DISCHARGE

NAME OF WAR

SERVICE NUMBER V.A. CLAIM NUMBER

PLACE OF ENLISTMENT PLACE OF DISCHARGE

ENLISTMENT DATES

WHERE ARE THE DISCHARGE PAPERS? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)

D.SPOUSE/PARTNER SPOUSE/PARTNER NAME SOCIAL SECURITY NUMBER



HOME PHONE CELL PHONE

EMPLOYER TELEPHONE

ADDRESS

E. FORMER SPOUSE/PARTNER SPOUSE/PARTNER NAME SOCIAL SECURITY NUMBER



HOME PHONE CELL PHONE

EMPLOYER TELEPHONE

ADDRESS


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F. CHILDREN, GRANDCHILDREN, OTHER INDIVIDUALS TO BE CONTACTED

NAMERELATIONSHIPDATE OF BIRTHSS NUMBER (if needed)ADDRESSEMAILHOME PHONECELL PHONE




NAMERELATIONSHIPDATE OF BIRTHSS NUMBER (if needed)ADDRESS


Date Revised ____________________

EMAILHOME PHONECELL PHONE

G.EMERGENCY CONTACT PERSON(S) NAME/RELATIONSHIP NAMERELATIONSHIPADDRESSEMAILHOME PHONECELL PHONEWORK PHONE

NAMERELATIONSHIPADDRESSEMAILHOME PHONECELL PHONEWORK PHONE

H.POWERS OF ATTORNEY 1. Financial Power of Attorney (POA) Information

It is prudent to review POA periodically and re-execute every five years.AGENT NAMED IN POA EMAILDATE POA NAMED DATE OF POA RE-CERTIFIED

ADDRESS (Street, City, State, Zip)


WHERE IS THE DOCUMENTATION LOCATED? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)

ALTERNATE AGENT NAMED IN POA EMAILDATE ALTERNATE AGENT NAMED DATE ALTERNATE AGENT RE-CERTIFIED





Date Revised ____________________

2. Power of Attorney for Health Care (POA-Health Care) InformationIt is prudent to review POA-Health Care periodically and re-execute every five years.

AGENT NAMED IN POA-HEALTH CARE EMAILDATE POA-HEALTH CARE NAMED DATE OF POA-HEALTH CARE RE-CERTIFIED




ALTERNATE AGENT NAMED IN POA-HEALTH CARE EMAILDATE ALTERNATE AGENT NAMED DATE ALTERNATE AGENT RE-CERTIFIED




I. HEALTH INSURANCE 1. Medicare Health Insurance

NAME OF BENEFICIARY MEDICARE NUMBER

HOSPITAL INSURANCE (PART A) EFFECTIVE/ENROLLMENT DATE

MEDICAL INSURANCE (PART B)EFFECTIVE/ENROLLMENT DATE

PROVIDER’S NAME PROVIDER’S TELEPHONE

PROVIDER’S ADDRESS

WEBSITE EMAIL

AGENT’S NAME AGENT’S TELEPHONE

AGENT’S ADDRESS

AGENT’S WEBSITE AGENT’S EMAIL

WHERE CAN YOUR MEDICARE CARD BE FOUND?


Date Revised ____________________


2. Prescription Drug Plan, Part DFor Medicare-Covered individuals this will be provided by a Part D plan or a Medicare Advantage (Part C) plan. Non-Medicare enrolled individuals may receive drug coverage through their primary health care or a separate plan. List the plan that provides prescription drug coverage, even if that plan is listed later when Health Care Coverage Insurance Plan information is asked for.

INSURANCE PROVIDER MEMBER NAMEPROVIDER’S ADDRESS

WEBSITE EMAIL


AGENT’S ADDRESS


SUBSCRIBER MEMBER ID NUMBER GROUP/ISSUER POLICY NUMBER

WHERE IS YOUR MEDICARE CARD?


3. Health Care Insurance PlanThe plan that provides health care coverage other than through Medicare Parts A and B. This may be a supplemental plan, a Medicare Advantage Plan (Part C) or a primary plan if not Medicare covered.

PRIMARY POLICY HOLDER(S)/SUBSCRIBER’S NAME

ENROLLMENT DATE INSURER/HMO/PPO NAMEINSURER/HMO/PPO ADDRESS

WEBSITE EMAIL


AGENT’S ADDRESS


SUBSCRIBER NUMBER GROUP/POLICY NUMBER

WHERE IS YOUR HEALTH CARE PLAN CARD?


Date Revised ____________________


J. DENTAL INSURANCE PRIMARY POLICY HOLDER(S) NAME

ENROLLMENT/EFFECTIVE DATE PLAN NAMEINSURER’S NAME TELEPHONE

ADDRESS

WEBSITE EMAIL

SUBSCRIBER/MEMBER NUMBER GROUP/POLICY NUMBER

WHERE IS YOUR DENTAL CARD?


K.OTHER MEDICAL INSURANCE PRIMARY POLICY HOLDER(S) NAME

ENROLLMENT/EFFECTIVE DATE PLAN NAMEINSURER’S NAME TELEPHONE

ADDRESS

WEBSITE EMAIL

SUBSCRIBER/MEMBER NUMBER GROUP/POLICY NUMBER

WHERE IS YOUR INSURANCE CARD?


L. MEDICAL CONTACTS 1. Primary Care Physician Information

CLINIC PHYSICIAN’S NAME



Date Revised ____________________

TELEPHONE WEBSITE

2. Specialist Physician InformationCLINIC PHYSICIAN’S NAMEADDRESS (Street, City, State, Zip)

TELEPHONE WEBSITE

3. Hospital PreferencesHOSPITAL PHYSICIAN’S NAMEADDRESS (Street, City, State, Zip)

TELEPHONE WEBSITE

M. OTHER INSURANCE 1. Life Insurance

Duplicate section for additional policies.POLICY HOLDER(S) NAME

ENROLLMENT DATE PROVIDER’S NAMEINSURER’S NAME INSURER’S TELEPHONE

INSURER’S ADDRESS

WEBSITE EMAIL


AGENT’S ADDRESS

WEBSITE EMAIL



2. Disability Insurance PolicyPOLICY HOLDER(S) NAME


Date Revised ____________________

ENROLLMENT DATE PROVIDER’S NAMEINSURER’S NAME INSURER’S TELEPHONE

INSURER’S ADDRESS

WEBSITE EMAIL


AGENT’S ADDRESS




3. Accidental Death Insurance PolicyPOLICY HOLDER(S) NAME

ENROLLMENT DATE PROVIDER’S NAME

INSURER’S NAME INSURER’S TELEPHONE

INSURER’S ADDRESS

WEBSITE EMAIL


AGENT’S ADDRESS




4. Long-Term Care Insurance PolicyPOLICY HOLDER(S) NAME

ENROLLMENT DATE PROVIDER’S NAME


Date Revised ____________________

INSURER’S NAME INSURER’S TELEPHONE

INSURER’S ADDRESS

WEBSITE EMAIL


AGENT’S ADDRESS




5. Home InsuranceDuplicate section for additional properties/policies.

POLICY HOLDER(S) NAME POLICY NUMBER

INSURER’S NAME INSURER’S ADDRESS


AGENT’S EMAIL WEBSITE


6. Auto InsuranceDuplicate section for additional properties/policies.







Date Revised ____________________

7. Other InsuranceDuplicate section for additional properties/policies.






N.APPOINTED AND LEGAL CONTACTS 1. Personal Representative

PERSONAL REP AS NAMED IN WILL EMAILADDRESS (Street, City, State, Zip)


WHERE IS THE DOCUMENTATION LOCATED? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.) Indicate if a will has been deposited during testator’s lifetime in local Wisconsin Circuit Court (optional).

ALTERNATE/ SUCCESSOR AGENT/PERSONAL REP EMAILADDRESS (Street, City, State, Zip)


2. Testamentary Trustee/Successor Trustees Information (Irrevocable Trust)

TRUSTEE NAMED IN IRREVOCABLE DOCUMENT EMAIL




ALTERNATE/SUCCESSOR TRUSTEE EMAILADDRESS (Street, City, State, Zip)


Date Revised ____________________


3. Testamentary Trustee/Successor Trustees Information (Revocable Trust)

TRUSTEE NAMED IN REVOCABLE DOCUMENT EMAIL




ALTERNATE/SUCCESSOR TRUSTEE EMAILADDRESS (Street, City, State, Zip)


4. Attorney InformationATTORNEY’S NAME EMAILFIRM



O.FAITH CONTACTS HOUSE OF WORSHIP NAME OF CLERGY


TELEPHONE WEBSITE

EMAIL

P. BANK, CREDIT UNION AND OTHER FINANCIAL CONTACTS 1. Bank and Credit Union

NAME OF INSTITUTION WEBSITEADDRESS (Street, City, State, Zip)


Date Revised ____________________

NAME OF FINANCIAL SPECIALIST TELEPHONE



2. Virtual Bank (Also known as branchless or Internet-only bank)These are banks without a physical location or branch network that offer services only via Internet banking or telephone banking.



3. AccountantACCOUNTANT’S NAME EMAIL

FIRM


CELL PHONE WORK PHONE

WEBSITE

4. Financial PlanningFINANCIAL PLANNER’S NAME EMAIL

FIRM WEBSITE



5. Brokerage (For investment and pre-tax accounts – 403(b) plans)BROKER’S NAME EMAIL

FIRM WEBSITE


Date Revised ____________________



Q.ORGANIZATIONS TO CONTACT UPON INCAPACITY, DISABILITY, OR DEATHThe agencies listed below administer health insurance and other benefit programs for University of Wisconsin employees and their spouses or partners. In case the subject of this LIVING LEDGER becomes disabled, incapacitated, or dies, the spouse, partner, or emergency contact should communicate with these agencies as soon as possible but no later than thirty days following the change of status. The agency representative will provide the proper documents and applications and the deadlines required to maintain benefits without interruption. The instructions should be followed carefully, and the deadlines met promptly.

For changes in pension annuity, health insurance, life insurance, and accumulated leave credit plans, be prepared to give the name of the deceased, date of death and birth of the deceased, social security number of the deceased, relationship to caller, and contact information for the caller.

1. Wisconsin Department of Employee Trust Funds -- RetireesADDRESS (Street, City, State, Zip)4822 Madison Yards Way, Madison, WI 53702-9100 or PO Box 7931; Madison, WI 53707(New Hill Farms Building)TELEPHONE WEBSITE608-266-3285 or 877-533-5020 http://etf.wi.gov

2. UW-Madison, Office of Human Resources – Current UW Employees

ADDRESS (Street, City, State, Zip)21 North Park Street, Suite 5101; Madison, WI 53715-1218TELEPHONE WEBSITE608-265-2237 https://www.ohr.wisc.edu/benefits

3. Social Security AdministrationADDRESS (Street, City, State, Zip)6011 Odana Road, Madison, WI 53719TELEPHONE ONLINE SERVICES800-772-1213 or 800-633-4227 https://www.ssa.gov/onlineservicesWEBSITEhttp://www.ssa.gov http://www.medicare.gov

R.OTHER ORGANIZATIONS TO CONTACT For example: Other insurance companies, tax-sheltered annuity vendors, government agencies, veter-ans’ affairs offices, long-term care policy (LTC) vendor, etc.


http://www.medicare.gov/

http://www.ssa.gov/

https://www.ssa.gov/onlineservices

https://www.ohr.wisc.edu/benefits

http://etf.wi.gov/

Date Revised ____________________

COMPANY OR AGENCY POLICY OR ACCOUNT NUMBER


TELEPHONE WEBSITE

EMAIL



TELEPHONE WEBSITE

EMAIL



TELEPHONE WEBSITE

EMAIL



TELEPHONE WEBSITE

EMAIL

SECTION V -- LOCATION OF DOCUMENTSA.AN OVERVIEW

This section identifies where the personal documents, as described in “CONTACT INFORMATION”, and other documents are kept.

B.WHERE ARE YOUR PERSONAL DOCUMENTS KEPT? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)

BIRTH/ADOPTION CERTIFICATE


Date Revised ____________________

MARRIAGE CERTIFICATEDIVORCE PAPERSMILITARY RECORDSCITIZENSHIP PAPERSPASSPORTLIST DOCUMENTS ON DIGITAL STORAGEOTHERNote: Copies of birth, marriage, death and divorce certificates, and records of declaration and termination

of domestic partnership for events occurring in Wisconsin are available from the Department of Health and Social Services.

Information at: https://www.dhs.wisconsin.gov/vitalrecords/record.htm. Search for “Vital Statis-tics (name of state)” to find comparable states’ offices.

C.WHERE ARE YOUR LEGAL DOCUMENTS KEPT? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)

WILL (ORIGINAL AND COPIES)REVOCABLE TRUSTMARITAL PROPERTY AGREEMENTIRREVOCABLE TRUSTFINANCIAL POWER OF ATTORNEYPOA FOR HEALTH CARELIST DOCUMENTS ON DIGITAL STORAGEOTHER

D.WHERE ARE YOUR BANK AND CREDIT UNION DOCUMENTS KEPT?(Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)

CHECKBOOKSCHECKBOOKSBANK OR CREDIT UNION STATEMENTS

E. WHERE IS YOUR SAFE DEPOSIT BOX? NAME OF FINANCIAL INSTITUTIONADDRESSSTELEPHONEBOX NUMBERNUMBER AND LOCATION OF KEYSWHO IS AUTHORIZED TO ACCESS BOX


Date Revised ____________________

F. WHERE ARE YOUR INVESTMENT DOCUMENTS KEPT? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)

BONDS (Original Certificates)STOCK CERTIFICATES (Original Certificates)MUTUAL FUNDSCDs (Original Certificates)IRAs403(B), 401(K), OR SIMILAR ACCTSMANAGED INVESTMENT ACCOUNTSOUTSTANDING LOANS TO OTHERSLIST DOCUMENTS ON DIGITAL STORAGE

G.WHERE ARE YOUR REAL ESTATE AND AUTOMOBILE DOCUMENTS KEPT?(Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)

PRIMARY RESIDENCEREAL ESTATE OWNED (Investment)VACATION PROPERTYTIMESHARESCAPITAL IMPROVEMENT RECORDS -- PRIMARY AND VACATION PROPERTIESPROPERTY TAX INFORMATIONPROPERTY DEEDS/TITLEMORTGAGE OR SATISFACTION INFORMATIONAUTOMOBILE TITLE/REGISTRATIONAUTOMOBILE TITLE/REGISTRATIONAUTOMOBILE TITLE/REGISTRATION

H.WHERE ARE YOUR INSURANCE DOCUMENTS KEPT? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)

AUTOMOBILEHOMEOWNERS/RENTERSLIFELONG-TERM CAREHEALTHDISABILITY OR INCOME CONTINUATIONEXCESS (PERSONAL) LIABILITY INSURANCEOTHER (Indicate Type)


Date Revised ____________________

I. WHERE ARE YOUR WISCONSIN EMPLOYEE TRUST FUNDS (ETF) DOCUMENTS KEPT?(Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.) If you cannot locate these ETF documents, you may request copies from ETF, PO Box 7931, Madison, WI 53707-7931. Include your social security num -ber and date of birth in the request. (http://etf.wi.gov/)

ANNUAL UW STAFF BENEFIT STATEMENT (Active Employee)ETF ANNUITY PAYMENT STATEMENTETF ACCUMULATED SICK LEAVE CREDITSETF MILITARY SERVICE CREDITIS BENEFICIARY INFORMATION UP-TO-DATE?

J. WHERE ARE YOUR INCOME TAX DOCUMENTS KEPT? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)

FEDERALSTATE

K.WHERE ARE YOUR OTHER FINANCIAL DOCUMENTS KEPT? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)

HEALTH SAVINGS ACCOUNTSOTHER (Specify)OTHER (Specify)

L. WHERE ARE YOUR PERSONAL DIGITAL PROPERTY DOCUMENTS KEPT?Make sure your estate plans comply with the Wisconsin Digital Property Act 300 of 2015 and Wisconsin Statutes Chapter 711 governing the disclosure, access, management, and disposal of ownership rights of digital property: a) email accounts and other electronic communications protected under federal privacy laws; b) data in smartphones, tablets, netbooks and computers, and other sales accounts, e.g., Amazon; c) online purchasing accounts, e.g., PayPal; online storage and cloud storage accounts, e.g., DropBox, Shutterfly, and Google Drive; d) webpages, domain names, usernames, blogs, social networking accounts, e.g., Facebook, Twitter, LinkedIn; and e) intellectual property rights in digital property, etc. Who would be concerned with access to digital property should an original user die or become disabled? Any fiduciary, from personal representatives, to guardians and conservators, to agents under powers of attorney, to trustees, would have a need to deal with digital property of the user.

Source: State Bar of Wisconsin/News Publications/Inside Track/Estate Planning in the Digital Age: Wisconsin’s New Digital Property Act Vol 8, Number 9, Dated May 2016Link to article: https://tinyurl.com/ycmo5mew .

The following checklist assists in highlighting the status of your documents and agreements that would allow access to your digital property.


https://tinyurl.com/ycmo5mew

http://etf.wi.gov/

Date Revised ____________________

1. Wills and TrustsYES NO Does your will/trust grant your personal representative/trustee the power to access, manage, and

dispose of the content of your digital property?WHERE IS THE DOCUMENTATION LOCATED? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)

2. Power of Attorney - FinanceYES NO Does your power of attorney for finance grant your personal representative the power to access,

manage, and dispose of the content of your digital property?WHERE IS THE DOCUMENTATION LOCATED? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)

3. Terms of Digital Service AgreementsYES NO Did you review your terms of digital service agreements with technology companies to see if you can

appoint a successor? Example: Google allows for a successor.WHERE IS THE DOCUMENTATION LOCATED? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)

4. Digital Password Management ProgramsYES NO Does your power of attorney for finance include authorization for your personal

representative/trustee access to your password manager programs? (e.g., Password, Dashline, Keepass, Last Pass)


5. Other Types of Personal Digital PropertiesDID YOU IDENTIFY WHO HAS ACCESS TO THE PERSONAL DIGITAL PROPERTIES LISTED BELOW?YES NO N/A

User names and passwordsEmail accountsData in smartphones, tablets, netbooks and computers, and online sales accounts (e.g., Amazon, eBay, financial institutions)Online purchase accounts (e.g., PayPal)Online storage and cloud storage accounts (e.g., Dropbox, Shutterfly and Google drive)Webpages, domain names, usernames, blogs and social networking accounts (e.g., Facebook, Twitter, LinkedIn)Intellectual property rights in digital property



Date Revised ____________________

SECTION VI -- FINANCIAL ASSET DOCUMENTATIONA.AN OVERVIEW

The Financial Asset Documentation section records the personal information on bank and credit union accounts, retirement plans, financial investments, real estate, loans, annuities, businesses, credit and debit cards, wills, and revocable and irrevocable trusts.

In completing the Financial Asset Documentation section of LIVING LEDGER, please consider the follow-ing suggestions.

Annual statements from pension plan administrators, financial institutions, brokerage firms, insurance companies, etc., contain the information required for completing this section. Consider documenting the location of periodic reports received. They may be inserted in a printed LIVING LEDGER you retain, or their physical or digital locations specified in paper or digital copies.

Prepare a list of all your financial institutions and update them annually.

Many of the financial assets listed in these documents ask for “basis” information. “Basis” refers to the cost at which an asset was purchased including commissions and other expenses. It is used to determine capital gains or losses for tax purposes when the asset is sold.

“Basis” for rental property can be affected by depreciation, capital improvements, reinvestments, etc. Also, there are special basis rules for inherited property and property that has been received as a gift. Be sure to consult with a tax professional if you are unsure or not knowledgeable about what value to assign as basis for assets listed in this LIVING LEDGER.

For investments held at a broker, your monthly statement will typically indicate the basis for an item.

B.BANK AND CREDIT UNION ACCOUNTS FINANCIAL INSTITUTION TELEPHONE

TYPE OF ACCOUNT (Checking, Savings, Money Market, CD) ACCOUNT NUMBER

NAME ON ACCOUNT BENEFICIARY (Payment on Death-POD or Transfer on Death-TOD)


FINANCIAL INSTITUTION TELEPHONE


NAME ON ACCOUNT BENEFICIARY (Payment on Death-POD) or Transfer on Death-TOD)


Date Revised ____________________


FINANCIAL INSTITUTION TELEPHONE


NAME ON ACCOUNT BENEFICIARY (Payment on Death-POD or Transfer on Death-TOD))


C.WISCONSIN EMPLOYEE TRUST FUNDS (ETF) RETIREMENT PLANS1. Pension (See Section IV. P.1. for detailed contact information)

PLAN NAME FINANCIAL INSTITUTIONWISCONSIN RETIREMENT SYSTEM STATE OF WISCONSIN EMPLOYEE TRUST FUNDSUW EMPLOYEE’S NAME ACCOUNT NUMBER

PAYMENT OPTION SELECTED IF RECEIVING PENSION BENEFITS

BENEFICIARY FOR PERIOD CERTAIN OPTION


2. Tax-Sheltered Annuity – Also known as 403(b) plansPLAN NAME FINANCIAL INSTITUTION

NAME ON PLAN ACCOUNT NUMBER

AGENT AGENT TELEPHONE

DID YOU NAME BENEFICIARIES? LIST


3. Deferred Compensation 457PLAN NAME FINANCIAL INSTITUTION



Date Revised ____________________




4. Other (e.g., Roth) PLAN NAME PLAN TYPE

FINANCIAL INSTITUTION





D.OTHER RETIREMENT PLANS 1. IRA (401K)

PLAN NAME PLAN TYPE






2. Other Plans (529 College Plans, e.g., Edvest)PLAN NAME PLAN TYPE




Date Revised ____________________




3. Other Plans PLAN NAME PLAN TYPE






E. MANAGED INVESTMENT ACCOUNTS If you have a “managed investment account”, complete the following contact information for each account. You may have a managed account for each spouse or partner and one held jointly. Accounts of this kind are usually managed by a brokerage firm, a bank, a financial services corporation, or another financial institution. For those assets included in your managed account, you may substitute your annual statement sent to you by your account manager for the individual documentation outlined in LIVING LEDGER. It is recommended that you update this section each year, and with the new annual statement, if preferred. Plan types include brokerage, IRA, ROTH IRA, etc.

FINANCIAL INSTITUTION CUSTODIAL FIRM

MANAGER TELEPHONE

NAME ON ACCOUNT

ACCOUNT TYPE ACCOUNT NUMBER

DISPOSITION AT DEATH TO



Date Revised ____________________

FINANCIAL INSTITUTION CUSTODIAL FIRM

MANAGER TELEPHONE

NAME ON ACCOUNT

ACCOUNT TYPE ACCOUNT NUMBER

DISPOSITION AT DEATH TO


F. INVESTMENT ACCOUNTS (STOCKS AND PARTNERSHIPS) A quarterly or annual statement may be substituted for some of the items below and may be attached.

BROKERAGE FIRM

BROKER’S NAME TELEPHONE

NAME(S) ON ACCOUNT TRANSFER ON DEATH TO, IF ANY

LIST OF EQUITIES


EQUITY DESCRIPTION (STOCKS)

NAME(S) ON STOCK CERTIFICATE NUMBER OF SHARES

TRANSFER ON DEATH TO


EQUITY DESCRIPTION (PARTNERSHIPS)

NAME(S) ON STOCK NUMBER OF SHARES

TRANSFER ON DEATH TO



Date Revised ____________________

G.BOND PORTFOLIO INVESTMENT INFORMATION A quarterly or annual statement may be substituted for some of the items below and may be attached.

BROKERAGE FIRM

BROKER’S NAME TELEPHONE

DESCRIPTION OF BONDS (CORPORATE)

FACE VALUE MATURITY DATE

NAME ON ACCOUNT TRANSFER ON DEATH TO


DESCRIPTION OF BONDS (MUNICIPAL)


NAME(S) ON BOND TRANSFER ON DEATH TO


DESCRIPTION OF BONDS (OTHER)


NAME(S) ON BOND TRANSFER ON DEATH TO


H.MUTUAL FUND INVESTMENT INFORMATION A quarterly or annual statement may be substituted for some of the items below and may be attached.

FINANCIAL INSTITUTION OR BROKERAGE FIRM TELEPHONE

ACCOUNT NUMBER TRANSFER ON DEATH TO

NAME(S) ON FUND ACCOUNTWHERE IS THE DOCUMENTATION LOCATED? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)



Date Revised ____________________






I. REAL ESTATE – HOMESTEAD AND OTHER REAL ESTATE INFORMATION

TYPE (Homestead, Vacation Investment, etc.) LOCATION

NAME(S) ON TITLE DOCUMENT

PURCHASE PRICE AND DATE (COST BASIS) ASSET VALUE AND DATE

MORTGAGE HOLDER ACCOUNT NUMBER

HOME EQUITY LOANS OTHER (Renter Info, Loan Payment Protection, etc.)

LIST OF CAPITAL IMPROVEMENTS (ADD TO COST BASIS)


TYPE (Homestead, Vacation Investment, etc.) LOCATION

NAME(S) ON TITLE DOCUMENT

PURCHASE PRICE AND DATE (COST BASIS) ASSET VALUE AND DATE

MORTGAGE HOLDER ACCOUNT NUMBER

HOME EQUITY LOANS OTHER (Renter Info, Loan Payment Protection, etc.)

LIST OF CAPITAL IMPROVEMENTS (ADD TO COST BASIS)

WHERE IS THE DOCUMENTATION LOCATED? (Be specific. Indicate file drawer and file label, safe deposit box, digital


Date Revised ____________________

storage, etc. Note that if accessed on the web, the password should be separately stored.)

J. NOTE(S) AND LOAN(S) PAYABLE INFORMATION (Money you owe - DEBT)

TYPE OF LOAN

LENDER BORROWER

AMOUNT OUTSTANDING/DATE TERMS


TYPE OF LOAN

LENDER BORROWER



TYPE OF LOAN

LENDER BORROWER



K.IMMEDIATE TAX DEFERRED OR VARIABLE ANNUITIES INFORMATIONWithdrawal from tax-deferred annuity may be subject to required minimum distribution (RMD) requirements.

ANNUITY CARRIER

TYPE

POLICY NUMBER ANNUITANT

BENEFICIARIES SURRENDER VALUE


Date Revised ____________________

AGENT CONTACT INFORMATION


L. BUSINESS AND PARTNERSHIPS INFORMATION NOTE: For each business or partnership, append relevant information (e.g., appraisals, cash flow state-

ments, tax documents, description of assets, list of officers, copies of stock certificates).NAME OF BUSINESS

NAME(S) OF OWNERS

LOCATION TELEPHONE

TYPE (S CORP/C CORP/LLC)


NAME OF PARTNERSHIP

NAME(S) OF OWNERS

LOCATION TELEPHONE

TYPE (S CORP/C CORP/LLC)


M. TANGIBLE ASSET INFORMATION 1. Automobiles, Boats, Planes, etc.

Reminder: If married and living in Wisconsin, titles of tangible assets are presumed to be marital property.

TYPE DESCRIPTION/VIN NUMBER

NAME(S) ON TITLE DOCUMENT MARKET VALUE/DATE VALUED

IS THE ASSET INSURED? (YES/NO) POLICY NUMBER

INSURER NAME INSURER ADDRESS




Date Revised ____________________
















2. Jewelry, Art, Rare Books, Collectibles, Musical Instruments, etc.Reminder: If married and living in Wisconsin, jewelry, art, etc. are presumed to be marital property.

DESCRIPTIONOWNER(S)PURCHASE PRICE/DATEMARKET VALUE/DATE VALUEDLAST APPRAISED BYDATE OF LAST APPRAISALWHERE IS THE DOCUMENTATION LOCATED? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)


Date Revised ____________________

DESCRIPTIONOWNER(S)PURCHASE PRICE/DATEMARKET VALUE/DATE VALUEDLAST APPRAISED BYDATE OF LAST APPRAISALWHERE IS THE DOCUMENTATION LOCATED? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)

N.CREDIT AND DEBIT CARD INFORMATION Note: For security reasons, PINs and passwords should not appear in this document.

TYPE (VISA, Mastercard, Discover, etc.) NAME OF PROVIDER (Bank, Credit Union, etc.)

CUSTOMER SERVICE CONTACT

NAME(S) ON CARD(S) ACCOUNT NUMBER

TELEPHONE FOR BALANCE TELEPHONE TO CANCEL

TELEPHONE TO REPORT FRAUD MAKE COPIES OF BOTH SIDES OF CARDS

PAYMENT METHOD (Check, Electronic Fund Transfer – from/to, etc.)


TYPE (VISA, Mastercard, Discover, etc.) NAME OF PROVIDER (Bank, Credit Union, etc.)

CUSTOMER SERVICE CONTACT

NAME(S) ON CARD(S) ACCOUNT NUMBER

TELEPHONE FOR BALANCE TELEPHONE TO CANCEL

TELEPHONE TO REPORT FRAUD MAKE COPIES OF BOTH SIDES OF CARDS

PAYMENT METHOD (Check, Electronic Fund Transfer – from/to, etc.)


O.OTHER PROPERTY INFORMATION TYPE


Date Revised ____________________

DESCRIPTIONNAME(S) ON TITLE DOCUMENTMARKET VALUE/DATE VALUEDWHERE IS THE DOCUMENTATION LOCATED? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)

TYPEDESCRIPTIONNAME(S) ON TITLE DOCUMENTMARKET VALUE/DATE VALUEDWHERE IS THE DOCUMENTATION LOCATED? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)

TYPEDESCRIPTIONNAME(S) ON TITLE DOCUMENTMARKET VALUE/DATE VALUEDWHERE IS THE DOCUMENTATION LOCATED? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)

P. WILL INFORMATION DATE SIGNED LOCATION OF ORIGINAL

NAME OF ATTORNEY ATTORNEY’S FIRM


ATTORNEY’S TELEPHONE ATTORNEY’S EMAIL

Q.REVOCABLE TRUST INFORMATION TITLE OF TRUST

DATE SIGNED LOCATION OF ORIGINAL

AMENDMENTS

GRANTOR(S)

TRUSTEE(S) TRUSTEE(S) TELEPHONE




Date Revised ____________________


FINANCIAL INSTITUTION MANAGING ASSETS

ACCOUNT ADMINISTRATOR AND TELEPHONE

ACCOUNT NUMBER VALUE OF ASSETS UNDER MANAGEMENT/DATE

CURRENT BENEFICIARIES REMAINDER BENEFICIARIES

LIST OF ASSETS IN TRUST (Attach list or refer to file)


R.IRREVOCABLE TRUST INFORMATION TITLE OF TRUST

DATE SIGNED LOCATION OF ORIGINAL

GRANTOR(S)

TRUSTEE(S) TRUSTEE(S) TELEPHONE




FINANCIAL INSTITUTION MANAGING ASSETS

ACCOUNT ADMINISTRATOR AND TELEPHONE

ACCOUNT NUMBER VALUE OF ASSETS UNDER MANAGEMENT/DATE

CURRENT BENEFICIARIES REMAINDER BENEFICIARIES

IS BENEFICIARY GIVEN POWER OF APPOINTMENT? HAS POWER OF APPOINTMENT BEEN EXERCISED THROUGH WILL OR TRUST?

LIST OF ASSETS IN TRUST (attach list or refer to file)



Date Revised ____________________

SECTION VII -- HEALTH CARE DOCUMENTATIONA.AN OVERVIEW

This section contains information on health care documents, which include the Power of Attorney for Health Care and the Declaration to Physicians (Living Will) that upon completion empower your right to express your wishes and control decisions about your future medical care, including the right to accept or refuse treatment under certain circumstances. This section of the LIVING LEDGER is intended only as a basic overview of health care documents, presenting guidance on their importance and what information they provide. It is not intended as a fully detailed description. Please seek information from other resources, including your attorney, to assure that you meet the legal requirements for these documents to be honored by health care providers and your designated health care agents.

The UWRA periodically presents programs on health care and end-of-life issues. One recent presenta-tion relevant to this section of the LIVING LEDGER is Financial and Health Risks in Retirement: The Pro-tective Role of Powers of Attorney (19 January 2016) presented by Attorney Shanna Knueppel. The vid-eo of that presentation is at https://www.youtube.com/watch?v=fMJxDmEwm70. We urge you to listen to this presentation, which presents detailed guidance on how to complete these documents and the life and health circumstances that affect how these documents are written and activated.

The State Bar of Wisconsin has produced a guide to advance directives: A Gift to Your Family: Planning Ahead for Future Health Needs. This can be ordered by searching at www.wisbar.org.

The design and content of the legal documents themselves are updated periodically because of new leg-islation. You are encouraged to monitor these developments and review your documents at least annu-ally. The State Bar guide referenced above is now in its eighth edition, being regularly updated when necessary.

Copies of these documents should be shared with your health care agents, your physicians, and the hos-pitals and clinics where you obtain medical care. When updated, the shared documents should be replaced to assure the legality of the documents when activated, and that those helping you make deci -sions or making decisions on your behalf are aware of your current wishes.

B.ADVANCE DIRECTIVES AND MEDICAL AUTHORIZATIONS Wisconsin statutes recognize two forms of advance directives: Power of Attorney for Health Care (POA-Health Care) and Declaration to Physicians (Living Will). The standard forms legally recognized in the State of Wisconsin are available by searching for “end of life planning” at www.dhs.wisconsin.gov. If these do not reflect your wishes or circumstances, consult an attorney for changes. Note that your health care directives must be appropriately worded and properly witnessed to carry legal power.

1. Power of Attorney for Health Care (POA-Health Care)The POA-Health Care permits an individual to designate an agent who will make medical decisions that reflect the individual’s desires when the individual is incapable of doing so. Note that it is your responsibility to inform your agents that you have made that designation. To avoid misunderstand-ings, disputes, and delays in your health care, it is very important that you keep your health care agents, family members, partners and close friends informed about your designation of health care


https://www.youtube.com/watch?v=fMJxDmEwm70

Date Revised ____________________

agents and update these documents promptly about any changes that are required by changes in your circumstances or wishes and by changes in health care law.

Your POA-Health Care will take effect when two doctors sign a form saying that you no longer can make medical decisions. This determination may be because of the sudden onset of a debilitating condition or because of gradual mental deterioration. POA-Health Care responsibilities require the agent speak regularly to your health care providers and be informed about your treatment plans. Besides assuring your treatment is consistent with your wishes, agents may be asked to approve medical treatments and accompany you to medical appointments. For this reason, it is recom-mended that you pick an agent that is geographically close to you and your health care providers.

You can name successor agents, indeed as many as you wish, for each to take responsibility if the prior person cannot or chooses not to act. Note that once you have been declared unable to make medical decisions, you cannot change your agent designations. Nor may agents, if unable or unwill-ing to fill that role, name additional agents.

Your agent is not accountable to any oversight body. Thus, the person having potential power over your health care decisions should be well trusted. If there is no agent designated or no designated agent is available or willing to serve when you are deemed unable to make your own health-care decisions, a legal proceeding to establish guardianship is the fail-safe option.

Guardians are appointed by the court; these may be family member, friends, or third-party private organizations set up to provide these services. Guardians are accountable (i.e., bonded and insured).

Some agent’s powers are restricted by the POA-Health Care standard form. One that may concern individuals thinking about later care needs is the power to authorize admission to a long-term care facility. You may limit the ability of your agent to approve admission to a nursing home or community based residential facility for more than a short-term stay (generally three months or less). The POA-Health Care form asks if you permit or deny permission for longer-stay admission by your agent. It is recommended that you indicate “YES”; otherwise a court order would be required if such admission would be needed for more than three months (e.g., for rehabilitation), a potentially costly and time-consuming process. The medical caregiver may petition for permission, even if the agent denies it, a potential disagreement that is better resolved by choosing an agent who will make residential facility decisions with attention to your best interest. POA-Health Care agents may not admit an individual to a mental health treatment facility.

POA-Health Care are state-specific documents. It is advised that individuals spending a significant amount of time in another state have a separate POA-Health Care that is consistent with that state’s statutes and the availability of agent(s) and medical care.

2. Declaration to Physicians, also known as Living WillThe Declaration to Physicians states your preferences for life-sustaining treatment or a feeding tube withdrawal if you are in a terminal condition or in a persistent vegetative state. Note these two life conditions are medically defined in the legal document available on line.

The Declaration to Physicians does not empower anyone to make decisions for you; it only directs those who have responsibility for your care whether to withhold or withdraw specific life-sustaining treatment.


Date Revised ____________________

If your POA-Health Care document includes instructions for end-of-life care or you have conveyed your wishes to your agent, a separate Living Will may not be necessary. If you have both documents, be sure the two documents agree.

Copies of both documents, the POA-Health Care and Living Will, which are as valid as the originals, should be given to your physician, agents, clinics—anyone who may be involved in what medical decisions may be made for you.

3. Physician Orders for Life-Sustaining Treatment (POLST)A third advance directive (POLST) is being advocated nationally with varying legal status in the states. Currently only the La Crosse area in Wisconsin offers a program that has been “endorsed” by the national organization as having “addressed legal and regulatory issues associated with POLST and have developed strategies for ongoing implementation and quality assurance”.

The POLST form is designed to address care issues that are likely to be faced by terminally ill or frail individuals. It is intended to increase communications for these individuals with their health care providers about what specific medical interventions are likely in the very near future and what the individual may wish to receive or avoid. Note that it is not a substitute for a Living Will. The POLST national organization recommends it only for those facing a terminal illness, for which likely paths of treatment can be specified by the medical care providers. It is an actionable medical plan. For this reason, the original must be signed by the relevant care provider and must accompany the person when treated. For more details see the national POLST website at http://polst.org .

4. Do Not Resuscitate Order (DNR) and BraceletHaving a DNR order and bracelet instructs emergency responders not to attempt resuscitation through chest compression, inserting airways, administering cardiac resuscitation drugs, or to breathe for you, or to use electric shock to start your heart. They may clear airways, administer oxygen, control bleeding, provide pain medication, and contact a hospice or home health agency if either has been involved in your care.

A DNR bracelet is intended for those with a terminal condition or a condition that makes it likely that cardiopulmonary resuscitation (CPR) will be harmful or unsuccessful. Only physician-ordered DNR bracelets are legal in Wisconsin. To obtain a DNR bracelet, you must ask a physician for the bracelet, both you and the physician must sign the order, and the physician or a representative must place the bracelet on your wrist. You may reverse your order by informing your physician or simply removing your bracelet.

For more information on a DNR order and bracelet, talk to your physician or call the Wisconsin Department of Health Services at 608-266-1568.

5. Authorization for Sharing of Medical InformationThe Health Insurance Portability and Accountability Act (HIPAA), passed in 1996, regulates the collection, sharing, and use of individuals’ electronic health records, such as by insurance plans or care providers. It also gives individuals the right to examine, obtain copies of, and correct their


http://polst.org/about-the-national-polst-paradigm/what-is-polst/

Date Revised ____________________

health records. The U.S. Department of Health and Human Services provides information on HIPPA health information privacy and sharing at www.hhs.gov.

These regulations attempt to balance the need of health care providers for information in providing care and protection of that information from inappropriate disclosure. For this reason, information may be shared in some circumstances. It is useful to read the required descriptions from health care entities on how they use and share information about you in compliance with HIPAA.

Typically, individuals are informed of the way and to whom their medical information may be verbally disclosed, e.g., to further their medical care or secure payment of insurance claims. Health care providers may disclose personal health care information that is connected to an individual’s care, either with the individual’s permission or when the care provider reasonably presumes disclosure is consistent with good care. For example, if a patient invites a friend into the room, the care provider may assume information sharing is permitted. When a friend picks up an individual’s prescription, the pharmacy can assume permitted information sharing connected with that prescription. If you are unable to give or deny permission for medical information sharing, your care provider may share information with someone who is deemed to be involved in your care. Under these circumstances health care providers may ask a patient to sign a release form; it is not required they do so.

A useful guide on what and with whom information can be shared verbally is provided by the U.S. Department of Health and Human Services: “A PATIENT’S GUIDE TO THE HIPAA PRIVACY RULE: When Health Care Providers May Communicate About You with Your Family, Friends, or Others Involved In Your Care” at https://www.nextstepincare.org/uploads/File/consumer_HIPAA.pdf.

HIPAA regulations allow you to designate specific individuals with whom providers can share medical information. Without this specific designation, anyone asking for medical information would not, by law, be allowed access to that information. If you wish specific members of your family, friends, or a third party to obtain your medical information, a form indicating that wish must be in your medical records. State-specific forms are available at https://eforms.com/release/medical-hipaa/ .

C.YOUR HEALTH CARE AND MEDICAL RECORD INFORMATION AND LOCATIONThis section is only a guide that may be helpful in your organizing what health care documents you have and where your health care agents may find copies if they do not have their own. You should consult your health care providers and your lawyer about what is needed in your circumstances and where they are best stored. This form is fillable and editable, so you can adapt it to your situation.

1. Advance Directive and Medical Authorization Informationa. POWER OF ATTORNEY FOR HEALTH CARE (POA-Health Care). Names listed in successor order.

NAME OF POA-HEALTH CARE AGENT CONTACT INFORMATION GIVEN A COPY?YES NOT YET


https://eforms.com/release/medical-hipaa/

Date Revised ____________________

b. LOCATION OF POA-Health Care DOCUMENTS (Place, Name, Address)YOUR OWN COPYHOSPITALPHYSICIANSOTHER FAMILY/FRIENDS

c. DECLARATION TO PHYSICIANS – LIVING WILL (Place, Name, Address)YOUR OWN COPYHOSPITALYOUR POA-HEALTH CARE AGENTSPHYSICIANSOTHER FAMILY/FRIENDS

d. PHYSICIAN ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST)POLST _____ YES, I HAVE ONE _____NO, I DO NOT HAVE ONELOCATION OF CURRENT/ORIGINAL POLSTHEALTH CARE PROVIDER SIGNING FORM

2. Medical InformationIncreasingly health care providers are offering patients an internet connection to access a portion of their medical records, including a list of medications. If you registered to use such a program indi -cate the website; your password and ID should be recorded separately from LIVING LEDGER with your other passwords, PIN numbers, and access code. If desired, attach list.

DO YOU HAVE A LIST OF MEDICATIONS ELSEWHERE? _____YES _____ NOIF YES, WHERE IS LIST LOCATED?WHAT HEALTH CARE PROVIDER IS BEST TO CONTACT FOR THIS INFORMATION? PHYSICIAN HOSPITAL/CLINIC OTHER PLACE TO FIND THIS INFORMATION

SOME HEALTH CARE PROVIDERS OFFER PATIENTS A WEBSITE TO ACCESS PERSONAL MEDICAL RECORDS. IF YOU USE SUCH A SITE, INDICATE WEBSITE AND LOCATION OF LOGON/PASSWORD.


Date Revised ____________________

SECTION VIII -- ORGAN, TISSUE, AND BODY DONATIONSIf you wish to be an organ donor, you can indicate that wish by signing the back of your driver’s license or state ID card, by filling out the uniform donor card, or by completing the anatomical gift addendum of Wisconsin’s POA-Health Care form. Most importantly, express those wishes to your family, physician and health care agents. You can find the forms to register to donate with a search for “Organ and Tissue Donation Program” at www.dhs.wisconsin.gov.

The booklet “A Gift to Your Family: Planning Ahead for Future Health Needs”, available through the State Bar of Wisconsin, has a uniform donor card you may wish to carry in your wallet.

A.ORGAN AND TISSUE DONATIONS Check answers if completing online YES NO

DO YOU WISH TO MAKE AN ANATOMICAL GIFT UPON YOUR DEATH?NOTED IN POA-HEALTH CARE?NOTED ON DRIVER’S LICENSE?NOTED ON ID CARD?DISCUSSED WITH FAMILYWHERE ELSE IS THIS INFORMATION?

B.BODY DONATIONS Check answers if completing online YES NO

HAVE YOU MADE ARRANGEMENTS FOR A BODY DONATION?NOTED IN POA-Health Care?NOTED ON DRIVER’S LICENSE?NOTED ON ID CARD?DISCUSSED WITH FAMILYWHERE ELSE IS THIS INFORMATION?

WITH UW MEDICAL SCHOOL?MEDICINE AND PUBLIC HEALTH BODY DONATION PROGRAM: TELEPHONE 608-265-3295. www.bdp.wisc.eduDATE DONATION FORM SUBMITTED?TELEPHONE TO CALL AT TIME OF DEATH

WITH MEDICAL COLLEGE OF WISCONSIN?ANATOMICAL GIFTS REGISTRY: TELEPHONE 414-955-8261. www.mcw.edu/Anatomical-Gift-Registry.htmDATE DONATION FORM SUBMITTED?TELEPHONE NUMBER TO CALL AT TIME OF DEATH

PERSON(S) RESPONSIBLE FOR CARRYING OUT DONOR’S INSTRUCTIONS, AND CONTACT INFORMATION


OTHER ARRANGEMENTS MADE


http://www.mcw.edu/Anatomical-Gift-Registry.htm

Date Revised ____________________

SECTION IX -- FUNERAL AND MEMORIAL INSTRUCTIONSThe Department of Health Services Division of Public Health “Authorization for Final Disposition” form is a voluntary document that when completed, signed, and witnessed, allows individuals to designate another person to make funeral arrangements on their behalf. It further allows individuals to state preferences for final disposition and funeral service.

The form can be found at https://www.dhs.wisconsin.gov/forms/advdirectives/f00086.pdf .

In 2017 the UWRA Retirement Challenges Committee compiled a document about local options for funeral homes and burial services, available at https://preview.tinyurl.com/y8wefyz3 .

As with indicating your health care wishes, it is most important to discuss your funeral/memorial wishes with your family and agents.

A.GUIDELINES FOR FUNERAL OR MEMORIAL SERVICES 1. Contact Upon Death

FUNERAL HOME, CHURCH, SYNAGOGUE, MOSQUE, MEETING HOUSE, FRATERNAL ORGANIZATIONS, ETC.RELATIVES, FRIENDS, UW DEPARTMENT/ UNIT, ETC. (If Preferred Attach List)

COMPLETED OBITUARY NOTICE AND FILE LOCATION

PREFERRED FUNERAL HOME

2. Memorial ConsiderationsTRADITIONAL SERVICE

Includes visitation, funeral service, committal service and burial, and reception

NONTRADITIONAL SERVICECould include nontraditional burial, entombment or cremation, private family viewing, memorial service, limited graveside service, or no service at all (immediate or direct disposition)


https://preview.tinyurl.com/y8wefyz3

https://www.dhs.wisconsin.gov/forms/advdirectives/f00086.pdf

Date Revised ____________________

3. Prepaid/Prearranged Funeral PlansName of funeral homeAddressTelephoneWHERE IS THE DOCUMENTATION LOCATED? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)

4. Considerations If Not Expressed in a Prepaid PlanGENERAL

Elaborate or simplePublic or privateReligious or secularMusic preferenceType of container for body or ashesWhere held

LEVEL OF EXPENSEPREPAID FUNERAL PLAN, BURIAL PLANSVETERAN HONOR GUARD OR TAPSFRATERNAL ORGANIZATION CEREMONYRELIGIOUS AFFILIATED ACTIVITYSUGGESTED PALLBEARERSMEMORIAL DONATIONS PREFERENCE(e.g., hospice, specific foundation, humane society)WHERE IS THE DOCUMENTATION LOCATED? (Be specific. Indicate file drawer and file label, safe deposit box, digital storage, etc. Note that if accessed on the web, the password should be separately stored.)

B.GUIDELINES FOR FINAL ARRANGEMENTS DISPOSITON OF BODY?(Ground, Mausoleum or Medical School)DISPOSITION OF ASHES? (Scattered, Burial, Storage or Urn, Where?)DISPOSITION (BURIAL) SITE:

Preferred locationPre-purchased burial site?Site contact information?

MONUMENT(granite, marble, bronze plaque or none)?INSCRIPTION ON MONUMENT?

C.DEATH CERTIFICATE (Needed for survivors)Funeral director and/or doctor submit death certificate to Register of Deeds. Consider requesting mul-tiple copies necessary to document death for insurance and financial institutions. If death has taken place in Wisconsin, and if extra copies are desired, submit an application to the Department of Health and Family Services (www.dhfs.wisconsin.gov/VitalRecords/death.htm).


http://www.dhfs.wisconsin.gov/VitalRecords/death.htm

Date Revised ____________________

For deaths after August 31, 2013, Wisconsin statutes now allow death certificates to be issued without requiring the “manner of death” to be listed. This may be preferred by survivors when presenting a death certificate, for example, to close cell phone plans, rental agreements, forms with motor vehicle companies. However, disclosure of cause of death is likely to be required on certificates presented to insurance companies, retirement plans and other financial asset management companies.

SECTION X -- OTHER INFORMATION THAT MAY BE IMPORTANTThis section is for important information that does not seem to fit into any prior category. Individual cir -cumstances vary greatly and will determine what should be recorded here, or placement of files indicated.PRIOR EMPLOYMENT HISTORY IN CASE THERE ARE EMPLOYMENT BENEFITS

ANNUAL CHARITABLE OR ENDOWMENT CONTRIBUTIONS

PETS

MULTI-YEAR PLEDGE(S) THAT YOU WANT HONORED UPON DEATH

SUGGESTED DISTRIBUTION UPON DEATH OF ANY TANGIBLE ITEM(S) NOT OTHERWISE LISTED

ANYTHING ELSE YOU THINK YOUR DESIGNATED REPRESENTATIVE OR HEIR(S) NEED TO KNOW


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