Page 15 The Islamic Bulletin Issue 18 THIS INFORMATION IS REQUIRED FOR THE DEATH CERTIFICATE: Full Name ___________________________________________________ Date Of Birth __________________________Place Of Birth____________ Social Security Number _______________________________________ Race Street Address And Zip ________________________________________ City/Town Of Residence ________________ County Of Residence_______ Full Name Of Father ________________________________________ First And Maiden Name Of Mother Highest Level Of Education In Years Elementary/Secondary (0-12) _______________ College (1-4 Or 5+)_____________________________ Marital Status (Circle): Never Married Married Widowed Divorced If Married Or Widowed, Name Of Spouse _______________________________________________ Usual Or Last Occupation ___________ Kind Of Business Or Industry __________________________ Name Of Attending Physician _________________________________________________________ Next of Kin and Contact info: THENETVALUEOF YOURESTATE I, ASSETS (Add up what you own and where located) A, Personal Property: 1.Cash ___________________________________Located: _________________________________________ Cash_______________________________________Located: _________________________________________ 2.Savings: _____________________________________ Bank _________________________________ Savings: __________________________________________________ Bank _________________________________ 3.Checking: _______________________________ Bank _______________________________________ 4.O t h e r : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5.Interest in Profit Sharing, Stock, Partnership, etc._____________________________________________ 6.Automobiles, Jewelry, Household & Clothing ____________________________________________ 7.Mi scel l aneous ________________________________________________________________ B, Real Estate (describe for each property you own) Value_________________________________________________________Located___________________________________ Value_________________________________________________________Located__________________________________ Total Value of all the above assets: II, LABILITIES (add what you owe) 1. _____________________________________________ Money Owed to _________________ $ Address and Phone: ________________________________________________________________________ 2. _____________________________________________ Money Owed to ________________ $ Address and Phone: ________________________________________________________________________ 3. _________________________________________________________________________ Mo r t g a g e 4. ___________________________________________________________________________ 5. Personal debts: (loans, car, etc.) ________________________________________________________ Total Amount owed: _________________________________________________________________ Safe Deposit Box__________________________ located at______________________________ Passport # &Type ____________________________ Important Passwords #: __________________________ This document, comprising ________pages, is made in _______ copies. The original is with me, one copy is deposited with _______________________________ Name and Phone # ___________________________and one copy with __________________________________ Name and Phone # WITNESSES On this day, ______________________________ date of____________________________________________ , the undersigned declared to us that this instrument was his/her Will and requested us to act as witnesses to it. He/She thereupon signed this Will in our presence, all of us being present at the same time. We now, at his/her request, in his/her presence, and in the presence of each other, subscribe our names as witness and declare that we understand this to be his/her Last Will, and that, to the best of our knowledge the testator is of the age of majority, or is otherwise legally empowered to make a Will, and under no constraint or undue influence. Witness 1.________ Name and Signature Witness 2.________ Name and Signature HEALTHCARE PROXYAND LIVINGWILL If the time comes when I am incapacitated and can no longer actively take part in decisions for my own life and am unable to direct my physician as to my own medical care, I wish this statement to stand as a testament of my wishes. I,_____________________________________________________________________________________________________________________________hereby appoint the following individual as my health care agent. Name: Phone# Address: This health care proxy shall take effect if and when I become unable to make my own health care decisions. In respect of each decision made for me by my agent, it is my wish and direction that my agent be guided solely by Islamic Shariah as to what my own decision would have been in the same circumstances. Without limiting the unrestricted scope of my agent’s authority hereunder, I expressly authorize my agent to direct that no treatment be conducted or withheld from me if to do so is against the teachings of Islam, to the best of understanding of my agent. I direct that medication be judiciously administered to me to alleviate pain. I do not intend any direct taking of my life. I also direct that "life support systems" may be used in a judicious manner and its use discontinued, just like any other medicine, if it becomes reasonably apparent that it has no curative value. The "life support systems" include but are not limited to artificial respiration, cardiopulmonary resuscitation, artificial means of providing nutrition and hydration, and any pharmaceutical drugs. I direct that my family, all physicians, hospitals and other health care providers and any court or judge honor the decision of my agent/alternate agent. This request is made, after careful reflection, while I am of sound mind. Name: ___________________________________________ Signature: Witness 1. Name and Signature Witness 2. Name and Signature ***OPTIONAL*** Subscribed and sworn to before me this ________________________day of _____________, Notary Public __________________________________________________________________________________________ Signature & Seal In Case of Emergency Contact: (Include Mosques and all phone numbers) We hope this will benefit you and your family. For a will to be legal in most states, you have to be at least 18 years old and of sound mind. The will must be signed by you and witnessed by two people who won't receive anything from your estate. However, please consult with an Islamic Scholar and/ or an attorney first. As always, please feel free to pass or share this information on to your friends and other Muslims. Pray for the people at The Islamic Bulletin who prepared this sample Will for you. Jazakum Allahu Khairan (May Allah Reward You). If more copies are needed please go to: www.islamicbulletin.org and click on enter here and then Islamic Last Will. For a list of mosques click mosques under enter here. You can print the whole mosques in a PDF format. Rev. 2009 For More Information Please Contact: The Islamic Bulletin P.O. Box 410186 Web: www.islamicbulletin.org San Francisco, CA 94141-0186 E-Mail: info@islamicbulletin.org http://www.islamicbulletin.org/services/testament.htm
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