2. Personal Records
MY NET WORTH STATEMENT
Assets (What you own) Current amount
Liquid assets Cash on hand $ _______________________________
Chequing/savings/broker accounts $ _______________________________
Canada Savings Bonds $ _______________________________
Term deposits/investment certificates $ _______________________________
Other $ _______________________________
Marketable assets Government/corporate bonds $ _______________________________
Common shares $ _______________________________
Preferred shares $ _______________________________
Mutual funds $ _______________________________
Real estate investments $ _______________________________
Other (business interest, farm, etc.) $ _______________________________
$ _______________________________
$ _______________________________
$ _______________________________
$ _______________________________
This booklet is Long-term assets Cash value of life insurance (also
indicate amounts to be received as death
designed to help you benefit by your estate upon your death) $ _______________________________
organize, in one handy Registered Retirement Savings/Income Plans $ _______________________________
Other (pensions/profit sharing plans, etc.) $ _______________________________
location, important
Personal assets Personal residence $ _______________________________
information about your Recreation property $ _______________________________
personal and financial Vehicles $ _______________________________
Household furnishings/equipment $ _______________________________
affairs. You’ll find it Other (art, coins, jewelry, etc.) $ _______________________________
provides a convenient Total assets $
record and will be easy Liabilities (What you owe) Current amount
to update. As well, it
Short-term debt Charge accounts/credit cards $ _______________________________
will help your survivors Loans/Lines of credit $ _______________________________
wind up your personal $ _______________________________
Taxes (income/property tax owing) $ _______________________________
affairs after your
Other (life insurance loans, etc.) $ _______________________________
death. Keep this Unpaid bills $ _______________________________
record in a safe place Long-term debt Home mortgage $ _______________________________
Other property mortgage $ _______________________________
along with your other Other (line of credit, margin account, etc.) $ _______________________________
important papers. Total liabilities $
Let your family know NET WORTH:
where it’s kept. Total assets minus total liabilities $
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3. Loan Agreements or promissory notes are located:
Debtors and Creditors People To Be Contacted
People who owe you money
Next of kin
Name:
Name: Name:
Amount: Date:
Relationship to you: Relationship to you:
Demand/Maturity date: Trust Funds Telephone: Telephone:
Address: Are you a beneficiary of any trusts? Address: Address:
❑ Yes ❑ No
Purpose:
Name: Name: Name:
Trustees are:
Amount: Date: Relationship to you: Relationship to you:
Trust papers are located: Telephone:
Demand/Maturity date: Telephone:
Address: Address:
Address:
Amount $:
Are you a trustee of any trusts?
People to whom you owe money
(other than previously listed) ❑ Yes ❑ No
Name: Purpose:
Amount: Date: Trust papers are located:
Demand/Maturity date:
Address:
Income Tax
Your tax advisor is:
Name:
Telephone:
Amount: Date:
Address:
Demand/Maturity date:
Address:
Your tax records and supporting data are located:
14 4 3
4. Banking Institution:
Other People To Be Contacted Residence & Real Estate Building cost figures (December 31, 1971 value
Telephone:
Executor or Liquidator (in Quebec): plus capital improvements to date):
Address: Type of Title is Is there a Mortgage
real estate held by mortgage? is held by
Telephone: (e.g. house, (circle one) (circle one) Mortgage insurance policy:
condo, etc.)
Address:
Banking Institution:
you yes
Telephone: spouse no
Address: joint
Employer/Business Office: Personal Property
you yes
List all vehicles you own:
spouse no
Telephone:
Investors Group Consultant: joint
Address:
you yes
Telephone: spouse no Vehicle registrations are located:
Address: joint
Lawyer:
you yes Bill of sale and insurance papers are located:
Telephone:
spouse no
Address:
Person(s) to whom you have granted joint
power of attorney:
Are household furnishings insured?
Where are the following located?
Notary (for Quebec residents):
Telephone: ❑ Yes ❑ No
Certificates of title:
Address: Bills of sale, an inventory of and insurance
Telephone: policies for household furnishings are located:
Copy of mortgages:
Address:
Others
Name: Property insurance policies: Jewelry, stamp collections, coin collections,
Accountant: appraisal documents, etc. are located:
Telephone:
Telephone: Land surveys:
Address:
Address: Collections/heirlooms/items of special value:
Property tax receipts:
Name:
Telephone:
Leases:
Address:
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5. Bank Accounts Safety Deposit Box Living Will Have you informed your
Be sure to list all your bank accounts, so Do you have a safety deposit box? Do you have a “Living Will” ❑ Doctor
your Executor, Liquidator or family can
❑ Yes ❑ No (if allowed in your province)? ❑ Next of kin
find the money you have in these
Location:
❑ Yes ❑ No ❑ Living Will representative
accounts.
If so, where is your Living Will kept? ❑ Mandatary or representative
(for residents of Quebec)
Names of others who have access to it:
Banking Institution Funeral Arrangements
Branch: For Quebec residents: Do you have a Have you made funeral arrangements?
Account #: “Mandate in Anticipation of Incapacity”
Location of the keys: ❑ Yes ❑ No
❑ Savings ❑ Chequing ❑ Joint ❑ Yes ❑ No
Funeral home & address:
If joint, who is joint owner? If so, where is such a document kept?
List of contents is located:
Telephone:
Branch: To whom have you given authority to
Location: make medical decisions on your behalf? Have you set out instructions in your
Account #: Will?
❑ Savings ❑ Chequing ❑ Joint ❑ Yes ❑ No
Names of others who have access to it:
If joint, who is joint owner? In a letter?
Organ Donation ❑ Yes ❑ No
Do you want to donate your organs or They are located:
Location of the keys:
Branch:
body for transplant, medical research
or education?
Account #:
List of contents is located: ❑ Yes ❑ No
❑ Savings ❑ Chequing ❑ Joint Do you own a cemetery plot?
If yes, explain:
If joint, who is joint owner? ❑ Yes ❑ No
Have you provided for its ongoing care?
Have you explained this in your ❑ Yes ❑ No
❑ Will and/or Living Will The plot is located:
❑ Organ donor card
❑ Driver’s license/Provincial Health Card
The deed to it is kept:
12 5
6. Your Will Pension Plans Are you a subscriber to a Registered
Education Savings Plan (RESP)?
Do you have a Will? ❑ Yes ❑ No Are you a member of a
Registered Pension Plan? ❑ Yes ❑ No
The original is located:
A copy is located:
❑ Yes ❑ No Account #:
Account #: Carrier name & address:
The Will was dated/last updated:
Carrier name & address:
Beneficiary:
Personal Records Beneficiary:
Date of Birth: Do you have a Registered Retirement
Place of Birth: Account #: Income Fund (RRIF)?
Birth certificate is located: Carrier name & address: ❑ Yes ❑ No
Account #:
Social Insurance/Social Security Number:
Beneficiary: Carrier name & address:
Citizenship Papers
Beneficiary:
Passport ❑ Yes ❑ No Do you have a Registered Retirement
Savings Plan (RRSP)?
They are located:
❑ Yes ❑ No Are you a member of a Deferred Profit
Marriage / Divorce Certificates
Account #: Sharing Plan (DPSP)?
Marriage certificate ❑ Yes ❑ No ❑ Yes ❑ No
Carrier name & address:
Divorce certificate ❑ Yes ❑ No Account #:
Located: Carrier name & address:
Beneficiary:
Account #: Beneficiary:
Current Military Service ❑ Yes ❑ No Carrier name & address: Information about this plan is located:
Discharge Papers are located:
Country of enlistment:
Beneficiary:
Veteran’s Number:
Do you leave a military pension? ❑ Yes ❑ No
6 11
7. Policy Number:
Investments Previous Employers Memberships
Carrier name & address:
Investment Funds Start with the first and put the current or List all memberships in clubs,
most recent employer last associations, subscriptions
❑ Yes ❑ No
❑ Acquired by gift or inheritance
Name of fund: Do you receive income from them? Employer: Name:
Account #: ❑ Yes ❑ No Year: Address:
Advisor’s name & address: Information about these annuities is located: Address/Location:
Registered owner(s): Name:
Bonds & Government investments Employer: Address:
Name of fund: ❑ Yes ❑ No Year:
❑ Acquired by gift or inheritance
Account #: Address/Location:
The form is:
Advisor’s name & address: Name:
Registered to:
Address:
Bearer:
Registered owner(s): Employer:
or co-registered with:
Year:
Serial numbers:
Name of fund: Address/Location: Name:
The bonds are located:
Account #: Address:
Advisor’s name & address:
Securities
Do you own any stocks or bonds? Employer:
Registered owner(s):
❑ Yes ❑ No Year: Domestic Contracts
❑ Acquired by gift or inheritance Address/Location: Do you have a:
Annuity Contracts Information about them is located: Co-habitation agreement? ❑ Yes❑ No
❑ Yes ❑ No Pre-nupital agreement? ❑ Yes ❑ No
❑ Acquired by gift or inheritance Are any of your securities pledged for Marriage Contract? ❑ Yes ❑ No
Policy Number: loans?
Separation Agreement? ❑ Yes ❑ No
Carrier name & address: ❑ Yes ❑ No
Divorce Order? ❑ Yes ❑ No
With whom:
The original is located:
10 7
8. Financial Commitments Charitable Gift Life Insurance Disability Insurance
Rent or Mortgage Payments For: Policies you own on your life: Company:
Amount $ Address: Company: Policy Number:
Due Date: Policy Number: Policy is located:
Lender/Address: Policy is located:
For: Beneficiary: Company:
Address: Policy Number:
Policy is located:
Outstanding loans/lines of credit/credit Company:
or charge cards/business Policy Number:
loans/guarantees
Contractual Obligations Policy is located: Company:
Amount $
For: Beneficiary: Policy Number:
Due Date:
Located: Policy is located:
Lender/Address:
Policies you own on others:
For: Company: Hospital & Medical Insurance
Located: Policy Number: Company:
Amount $
Policy is located: Policy Number:
Due Date:
For: Name of Insured: Policy is located:
Lender/Address:
Located:
Company: Company:
For: Policy Number: Policy Number:
Amount $
Located: Policy is located: Policy is located:
Due Date:
Name of Insured:
Lender/Address:
Other financial obligations Out of Province Travel Insurance
or commitments (auto lease,
Policies others own on your life: Company:
support/maintenance obligations)
Company: Policy Number:
Amount $ For:
Policy Number: Policy is located:
Due Date: Located:
Policy is located:
Lender/Address:
For: Owner of Policy:
Located:
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