Making a Will: St. John's Hospital

Your Guide to Making a Will	Today's Date:_______________
This worksheet is designed to assist you in organizing the necessary information needed to make a Will.
It is NOT a will, only a worksheet.

Your Name:	(First)________	(Middle)________	(Last)__________
Spouse:	(First)________	(Middle)________	(Last)__________
Address:	(Street)________	(City)__________	(State)_____	(Zip)____
SSN:	(You)________	(Spouse)________	(Day Phone)__________
Birthdate:	(You)________	(Spouse)________	(Evening Phone)________

Children/Grandchildren
(Name)	(Relation)	(Age)	(Address)	(Phone)
___________________	_____________	_____	______________________________	__________
___________________	_____________	_____	______________________________	__________
___________________	_____________	_____	______________________________	__________
___________________	_____________	_____	______________________________	__________
___________________	_____________	_____	______________________________	__________
___________________	_____________	_____	______________________________	__________
___________________	_____________	_____	______________________________	__________
___________________	_____________	_____	______________________________	__________

Financial/Business Planning Consultant Information
	Accountant	Attorney	Trust Officer	Stock Broker	Life Insurance Agent
Name	____________	____________	____________	____________	____________
Address	____________	____________	____________	____________	____________
Phone	____________	____________	____________	____________	____________

Current Inventory of Real Estate
Description	$ Value	Co-Owner Name(s)(If any)	Relationship (I.e. Joint, Tenants in Common, etc.)
__________________	_______	_____________________	_________________________
__________________	_______	_____________________	_________________________
__________________	_______	_____________________	_________________________
__________________	_______	_____________________	_________________________
__________________	_______	_____________________	_________________________

Current Inventory of Personal Property (i.e. jewelry, furniture, boat, car, motorcycle, ets.)
Description	$ Value	Co-Owner Name(s)(If any)	Relationship (I.e. Joint, Tenants in Common, etc.)
__________________	_______	_____________________	_________________________
__________________	_______	_____________________	_________________________
__________________	_______	_____________________	_________________________
__________________	_______	_____________________	_________________________
__________________	_______	_____________________	_________________________
__________________	_______	_____________________	_________________________
__________________	_______	_____________________	_________________________
__________________	_______	_____________________	_________________________

Bank Accounts, Cerificates of Deposits, Stocks, Bonds, and other Securities
(Account Number)	($ Amount)	(Institution Name & & Address	(Phone)
___________________	_____________	_______________________	____________
___________________	_____________	_______________________	____________
___________________	_____________	_______________________	____________
___________________	_____________	_______________________	____________
___________________	_____________	_______________________	____________
___________________	_____________	_______________________	____________
___________________	_____________	_______________________	____________
___________________	_____________	_______________________	____________
___________________	_____________	_______________________	____________
___________________	_____________	_______________________	____________

Life Insurance, IRA's, Retirement Plans (401 (k)), etc.
(Company)	(Beneficiary)	(Ownership)	($ Amount)
___________________	_____________	_______________________	____________
___________________	_____________	_______________________	____________
___________________	_____________	_______________________	____________
___________________	_____________	_______________________	____________
___________________	_____________	_______________________	____________

Distribution of Your Estate

State in your own words your wishes regarding the distribution of your estate:

__________________________________________________________________________________
__________________________________________________________________________________

Please list specific items you would like given to specific individuals.
(Person Designated)	(Description of property, item, or article)
_______________________	__________________________________________________________________
_______________________	__________________________________________________________________
_______________________	__________________________________________________________________
_______________________	__________________________________________________________________
_______________________	__________________________________________________________________

Would you like any charitable organizations to share in your Estate?
(Name of Orgaization)	(Phone)	($ Amount or	(% of Estate)
____________________________________	______________	____________	_____________
____________________________________	______________	____________	_____________
____________________________________	______________	____________	_____________

Designation of Important Persons
Executor of Your Estate:	Name:________________	Address_____________________
2nd Choice:	Name:________________	Address_____________________
Guardian for Minor Children:	Name:________________	Address_____________________
2nd Choice:	Name:________________	Address_____________________

Carroll Health Foundation is a non-profit supporting organization of St. John's Hospital - Berryville (SJHB.) SJHB is a private, non-profit hospital accredited by the Joint Commission on Accreditation of Healthcare Organizations and is affiliated with St. John's Health System - Springfield, MO.

This "Guide to Making" a Will is provided as a service of CARROLL HEALTH FOUNDATION, a supporting non-profit organization of St. John's Hospital - Berryville, 214 Carter Street, Berryville, Arkansas 72616
(870) 423-5245 or (800) 827-3355, ext. 55245

St. John's Hospital - Berryville 214 Carter Street Berryville, AR 72616 870-423-3355 800-827-3355 inf@stjohnsberryville.com