How about the date it was filled out? In a year, if I find it kicking around in my files, I won't know how current it is. In business documents I always have a date, and this deserves the same level of professionalism.
The other gap is the website address for each repository. In a printed form, it's useful, but not critical. But since I will be using this as an electronic form, it will be handy to have a clickable link on my iPad.
It's funny how our technology growth changes our perceptions. Last time I went to a courthouse, I didn't yet have an iPad. Now I don't know how I ever survived without it.
So here's the updated form.