Do you live by yourself? Yes ______ No ________
Do you have a life alert? _____________________________________________
Why not? ________________________________________________________________
If you hire a caregiver, have you done a background check on them? Yes______No_____
Have they been fingerprinted? Yes ______. No ________
References Provided? Yes ______. No ________
Do you have a “Payable on Death” on your financial statements? Yes_____No _____
Why not? _______________________________________________________________
Do you have a “Power of Attorney”? For Financial and Health? Yes ______ No ____
Why not?_______________________________________________________________
Did you know that your designated Power of Attorney no longer has authority to make
decisions once you’re gone? All decisions regarding your estate are now in the hands
of the Executor of your Trust/estate. Often POA’s are also Executors.
Do you have a “Do Not Resuscitate” (DNR)? Yes ________. No ________
Why not? _______________________________________________________________
Do you have a Living Will?” Yes _______. No________
It designates the person’s wishes in the event they cannot speak for themselves as
opposed to just saying Do Not Resuscitate.
Do you have a Trust? Yes ________. No __________
Why not? ________________________________________________________________
Do you have a Will? Yes __________ No __________
Why not? _______________________________________________________________
If you have assets more than $50,000, you need to have a Trust. (If you have only a Will,
the State will most likely send to probate court which could take up to two years to settle
in court, along with the court costs.
If you have prepared such documents, are they up to date with your attorney?
Yes _____ No ______
When were they last updated? __________
Are there changes that need to be made? Yes __________. No ________
Do you meet yearly with your executor(s) to make sure he/she understands your wishes after you are gone? ________________________________________________________
Does someone know where your financial/legal/medical documents are? Yes ___No___
Why not? _______________________________________________________________
Is your residence organized & decluttered? Yes _______. No _________
Why not? ________________________________________________________________
Have you gone through heirlooms, furniture, memento’s and items of personal significance to designate who receives what? Have you marked each item with tape or a tag to name who should get this when you’re gone?
What about electronics, lawn mower, tractor, tools, guns, jewelry? It is advised that you add to your Will a list of designated items with the names of who receives what. Sign and date this list to avoid any confusion. Some people meet individually with their children and grandchildren to ask them what they would like.
Have you stopped mail solicitations, catalogues, and unnecessary mailings? __________
Do not just throw them away, you must call them to Cease Sending.
Have you determined who will take care of your pets? Yes. ______ No _______
Have you considered a retirement facility? Yes _______. No _______
Do you think you might consider one within the next 3 years? Yes _______. No _______
What will you do when you can no longer drive? ________________________________
Do you have your utility bills and other regular bills on “Automatic Draft”? Yes __No__
Gather your computer account passwords.
Gather or provide information to close your business.
Gather proper identification.
Identify Accounts that should be closed or merged.
Determine any debts that need to be made aware.
Do you have a list made of your funeral arrangements? What would you like?
Do not pre-purchase funeral arrangements, just make your loved one know your wishes.
Are you an organ donor?
Do you have a pre-arranged funeral? (NOT prepaid) Yes__________No_____________
Have you educated yourself about Hospice? Hospice is for people who have been told by a doctor that they have less than 6 months to live. Most hospice care is done at home (90%). Hospice does not cover the cost of caregivers, but Hospice does provide a CNA to bathe the client twice a week, and nurses who are on-call 24/7 to check on the patient and keep the patient medically comfortable (these are usually 1-2 hour visits). Hospice also provides social workers and chaplains. If a patient is on Medicare, all Hospice expenses are completely covered including medications and medical equipment. Sometimes, they might have a volunteer to alleviate the home caregiver some time.