DATE OF INFORMATION: _________________________If you take the time to fill out
this section you will have at your fingertips most of the personal information and data that would be helpful not only in routine situations but in emergency situations which might arise during
your spouse's absence. The ready availability of this information in various situations could mean the difference between the timely provision of assistance or delayed problem resolution.
___________________________________________________
(Last Name, First Name, MI) (Social Security No.) (Rank/Grade)
COMPLETE UNIT/LOCAL ADDRESS/COMPLETE PERMANENT ADDRESS
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
I PERSONAL DATA:
1. Birth Date/ Location: ___________________________________________________
2. Naturalization (If applicable) on: ______________________ By: _________________
3. Parents: (Father, Name/Address) __________________________________________
______________________________________________________________________
(Mother, Name/Address) __________________________________________________
______________________________________________________________________
4. Marriage: Spouse: (incl. Maiden Name) ___________________________________
Date/Location: _______________________________________________
5. Children: (Full Names, Birth Date/Location)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
6. Personal lawyer or trusted friend who may be consulted regarding my personal and/or business affairs:
__________________________________________________________
7. Dependents other than immediate family:
________________________________________________________________________
________________________________________________________________________
II LOCATION OF FAMILY RECORDS:
1. Birth Certificates: Wife: ________________________________________________
Husband: _____________________________________________
Child: ________________________________________________
Child: ________________________________________________
Child: ________________________________________________
2. Naturalization Papers: Spouse: _________________________________________
Child: __________________________________________
Child: __________________________________________
3. Marriage Certificates: _______________________________________________
Divorce Papers: ____________________________________________________
Death Certificates: __________________________________________________
III MILITARY SERVICE PAPERS:
___________________________________________________________________________
IV OTHER IMPORTANT PAPERS:
1. Wife's Will: ____________________________ Resident of: ______________
Executor's Name: _______________________ City/State: _________________
2. Husband's Will: __________________________ Resident of: _____________
Executor's Name: _________________________ City/State: ______________
3. Power of Attorney: _____________________________________________________
Agent: _________________________________________________________________
4. Income Tax: Federal: __________________________________
State: ________________________________________________
City: _________________________________________________
V INSURANCE:
1. Life: __________________________________________________________
(Company) (Policy #) (Payment)
__________________________________________________________
(Company) (Policy #) (Payment)
2. Property: _____________________________________________________________
3. Medical: ______________________________________________________________
4. Other: ________________________________________________________________
VI SOCIAL SECURITY:
Wife: ____________________________ Husband: ________________________
Child: ____________________________ Child: ___________________________
Child: ____________________________ Child: ___________________________
VII PASSPORTS\VISAS:
Wife: ____________________________ Husband: _________________________
Child: ____________________________ Child: ____________________________
Child: ____________________________ Child: ____________________________
VIII PROPERTY:
1. Real Estate consisting of: ________________________________________________
_____________________________________________________________________
Located: ______________________________________________________________
Encumbered by: ________________________________________________________
Held by: ______________________________________________________________
2. Automobile: _________________________________________________________
(Make, Model, Year, State Registration)
Location: _______________________________________________________________
Insured with: ____________________________________________________________
Automobile papers located at: _______________________________________________
3. Other Personal Property: _________________________________________________
IX BANK ACCOUNTS: (Number, Bank, and Location)
Checking: ________________________________________________________________
Savings: __________________________________________________________________
Other (Specify): ____________________________________________________________
X SAFE DEPOSIT BOX at (Institution and Location with full address and telephone #)
_______________________________________________________________________
XI STOCK, BONDS, SECURITIES, INVESTMENTS:
1. Located at: ___________________________________________________________
2. Beneficiary: ___________________________________________________________
3. Document Serial Numbers: _______________________________________________
XII DESIGNATED BENEFICIARY: Names and addresses of persons designated on serviceman's
official record of emergency data form to receive settlement of unpaid pay and allowances in the event of death:
__________________________________________________________________________
__________________________________________________________________________
XIII DEBTS AND PAYMENTS:
(Agency, Company, Address, Amount Due, Date Payment Due)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
XIV FIRMS OR PERSONS INDEBTED TO YOU: (Name, Address, and Amount)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
XV ADDITIONAL DATA ON ANY OF THE PRECEDING ITEMS:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
