Please use additional pages if necessary to complete answers to any questions.

 

Date Prepared:_________________ †††††††††††

 

DEMOGRAPHIC INFORMATION

††

†††† 1.Husband:

††††††††† Name________________________________ †††† Nickname_____________

††††††

††††††††† Social security number______-______-_______

 

††††††††† Date of birth_____/_____/_____

 

††††††††† Total number of marriages (counting the current marriage) ______

 

††††††††† United States citizen?††† Yes______††† No______

 

†††† 2.Wife:

††††††††† Name:_______________________________ ††† Nickname_____________

 

††††††††† Social security number______-______-_______

††††

††††††††† Date of birth____/____/____

 

††††††††† Total number of marriages (counting the current marriage) ______

 

††††††††† United States citizen?††† Yes_____††† No_____

 

††††† 3.Full names of all children (adult and minor) and other dependents.Indicate the name of other parent if child is not of current marriage, or relationship if not a child, and if such person has any particular problems or needs, such as a physical or mental handicap.If address and telephone number are different, please list.Use back of page if necessary.Also, if the child or other dependent is commonly referred to by a nickname, please indicate the nickname.

†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Social†††††††††††††††††††††††† Birth†††††††††††††††††††† Marital

††††††††††††† Name†††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Security #†††††††††††††††††† Date†††††††††††††††††††† Status

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† †††††††††††††††††††††††††††††††††††††††††††††††††††††††(S,D,1st, 2nd W)

 

††††††††† _ †††________________________ †††††††††††††††††††††††††††††††________ †††††________ †††††††††††††††

 

††††††††† _ †††________________________ ††††††††††††††††††††††††††††††††________ ††††††_______

 

††††††††† _ †††________________________ †††††††††††††††††††††††††††††††________ ††††††_______

 

††††††††† _ ††________________________ †††††††††††††††††††††††††††††††________ ††††††_______ ††

 

DEMOGRAPHIC INFORMATION continued

 

††† 4.†† County or City of Residence:________________________________

†††

††† 5.††† Home Address:_________________________________________

††† †††††††City:___________________ †† State:_____________ †† ZIP:______

 

††† 6.††† Office Address:_________________________________________

††† †††††††City:___________________ †† State:_____________ †† ZIP:______

†††

††† 7.††† Billing Address (Check preference):††† Home_______††† Office_______

†††††††††† Other:____________________________________________________

†††††††††††††††††††††††††††††††††††††††††††††††††††††††† Please specify

 

††† 8.††† Phone Numbers:

 

†††††††††† Husband, work††† (_____)____________________

 

†††††††††† Wife, work††††††††† (_____)____________________

 

††††††††††† Home†††††††††††††††† (_____) ____________________

 

†† 9.††† Husbandís occupation:__________________________________________

 

†††††††††† Employer:____________________________________________________

 

†††††††††† Address:_____________________________________________________

 

†††††††††† City:_____________________________ State:____________ †† ZIP:_________

 

†††††††††† Annual Salary:_______________________

†††††††††† (Please furnish information on all benefits provided by employer, including retirement †††††† ††††††††††††††††

††††††††††† plans and group life insurance.)

 

†† 10.††† Wifeís occupation:____________________________________________

 

†††††††††††† Employer: __________________________________________________

 

††††††††††† Address: ____________________________________________________

 

††††††††††† City: ______________________________ †††State:__________ †† ZIP:_________

 

††††††††††† Annual Salary:______________________

††††††††††† (Please furnish information on all benefits provided by employer, including retirement††

†††††††††††† plans and group life insurance.)

 

 

ESTATE PLANNING CONSIDERATIONS

 

FIDUCIARIES:

 

At your death your executor will be responsible for collecting the assets of your estate, carrying out the directions contained in your will, ensuring that your will is properly probated, and filing any tax returns which may be due.

Your trustee will be responsible for investing any assets held in trust, preserving such assets for the beneficiaries of the trust, and distributing any assets to the beneficiaries according to the directions contained in any trust agreement which you might execute.

The guardian of your minor children will assume responsibility for such children in the event that both of you die before your children become adults.

Your agent will be allowed to make health care decisions for you if you are incapable of making them yourself.If you would like an advance medical directive and you wish to name either an agent other than your spouse or name an alternate agent, please write in the full name, home address and phone number of the person(s) you are naming.

 

Discuss these selections with the individual named before your first conference if possible.While a fiduciary should be a competent, responsible person, he or she may not have expertise in any of the areas mentioned, because he or she may always seek competent professional advice with respect to his or her duties and responsibilities.

 

11.      Do you have current wills, trust agreements, powers of attorney, or other estate planning†††††††††††††

††††††† documents?††††† Yes______†† No_______

†††††††††††††††††††††††††††††††††††††††††† (If yes, please bring them with you to your first conference.)

 

††† 12.†† Please indicate your preference for:

 

††††††††††† a.Husbandís:

†††††††††††††††† Executor:____________________________ †† State of Residence:_________

 

†††††††††††††††† Alternate:____________________________ †† State of Residence:_________

 

††††††††††††††††† Trustee:_____________________________ †† State of Residence:_________

 

†††††††††††††††† Alternate:____________________________ †† State of Residence:_________

 

††††††††††† b.Wifeís

†††††††††††††††† Executor:____________________________ †† State of Residence:_________

 

†††††††††††††††† Alternate:____________________________ †† State of Residence:_________

 

††††††††††††††††† Trustee:_____________________________ †† State of Residence:_________

 

††††††††††††††††† Alternate:____________________________ †† State of Residence:_________

 

ESTATE PLANNING CONSIDERATIONS continued

 

††††††††††† c.†† Guardian of minor children:________________________________________

††††††††††††††††† Guardianís state of residence:_______________________________________

 

††††††††††† d.†† Husbandís

††††††††††††††††† Agent for Advance Medical Directive:________________________________

††††††††††††††††††††† Home Address/Phone Number:___________________________________ †††††††††††

†††††††††† ††††††††______________________________________________________________

††††††††††††††††† Alternate:_______________________________________________________

††††††††††††††††††††† Home Address/Phone Number:___________________________________

††††††††††††††††† _______________________________________________________________

 

†††††††††† e.†† Wifeís

†††††††††††††††† Agent for Advance Medical Directive:________________________________

††††††††††††††††††††† Home Address/Phone Number:___________________________________

†††† †††††††††††††_______________________________________________________________

††††††††††††††††† Alternate:_______________________________________________________

††††††††††††††††††††† Home Address/Phone Number:___________________________________

††††††††††††††††† _______________________________________________________________

††

12.      At death, assuming no death tax consequences, how do you wish your property to be†††††††††††††††††††

††††††††††† distributed?

 

†††††††† Husband:

††††††††††† a.†† If your wife survives you?

 

 

†††††††††† b.†† If your wife does not survive you and minor children survive you?

 

 

†††††††††† c.†† If your wife does not survive you and all children are adults?

 

 

d.      If your wife does not survive you and all descendants still living are grandchildren or††††††††††††††††††††

††††† more remote descendants?

 

 

†††††††††† e.If your wife does not survive you and no descendants survive you?

 


ESTATE PLANNING CONSIDERATIONS continued

 

†† †††††Wife:

a.†† If your husband survives you?

 

 

†††††††††† b.†† If your husband does not survive you and minor children survive you?

 

†††††††††† c.†† If your husband does not survive you and all children are adults?

 

 

†††††††††† d.†† If your husband does not survive you and all descendants still living are grandchildren††††††††††††††††††

††††††††††††††† or more remote descendants?

 

†††††††††† e.If your husband does not survive you and no descendants survive you?

 

††† 14.†††† At what age do you want your children to receive their property outright

††††††††††††† (free of trust)?__________________________

 

††† 15.†††† Do you want to leave any property or cash to charity?†† Yes_____†††† No______

††††††††††††† (If yes, please attach a sheet indicating names and addresses of organizations and items††††††††††††††††††

†††††††††††††† or property or approximate amounts.)

 

††† 16.††† Do you want to leave any items of property (such as jewelry) or cash to certain persons?

†††††††††††† Yes______††† No_____†††††† (If yes, please attach a sheet indicating amounts, detailed††††††††††††††††††††

†††††††††††† descriptions of all items and the name of each recipient. Indicate relationship of recipient†††††††††††††††

†††††††††††† to donor, e.g., nephew, niece, friend, etc.)

 

††† 17.††† Other professionals with whom you do business:

 

†††††††††††††† a.Other Attorney(s)________________________ ††† Phone:__________________

 

†††††††††††††† b.Accountant: ____________________________ ††††Phone:________________

 

†††††††††††††† c.Trust Officer

††††††††††† ††††††††or Banker:_____________________________ †††† Phone:_________________

 

††††††††† †††††d.Insurance Agent:________________________ †††† Phone:_________________

 

†††††††††††††† e.Stockbroker:____________________________ †††† Phone:_________________

 

†††††††††††††† f.Investment/Financial

††††††††††††††††††† Advisor:_______________________________ ††† Phone:________________

 

††††††††††††† g.Real Estate Advisor:______________________ ††Phone:__________________

ESTATE PLANNING CONSIDERATIONS continued

 

††††††††† †††††h.Physician:______________________________ ††† Phone:__________________

 

†††††††††††††† i.Minister, priest, rabbi or

††††††††††††††††††† other religious counselor:__________________ †††† Phone:__________________

 

18.†† Life insurance policies:†† (Bring all policies to your first conference.Use additional sheets,†††††††††††††

††††††††† if necessary.)

 

††††††††††††††††††††††††††††††††††††††††††††††††††† Policy #1†††††††††††††††††††††††††† Policy #2††††††††††††††† Policy #3

 

Type of Policy††††††††††††††††††††††††† _______________________________________________

††† (Whole Life, Term, etc.)

Name of Insured†††††††††††††††††††††† _______________________________________________

Insurance Company††††††††††††††††† _______________________________________________

Policy Number††††††††††††††††††††††††† _______________________________________________

Face Amount††††††††††††††††††††††††††† _______________________________________________

Beneficiary†††††††††††††††††††††††††††††† _______________________________________________

Owner (who purchased)†††††††††† _______________________________________________

Annual Premium††††††††††††††††††††† _______________________________________________

Cash Value†††††††††††††††††††††††††††††† _______________________________________________

 

††††† a.††† Are there any loans outstanding on any of the above policies?†††† Yes_____††† No______

†††††††

††††† b.††† Ifyes, please furnish details in space below:

 

 

 

†††† ASSETS AND LIABILITIES

 

††† 19.†† Real Estate††††††††††††††††† ††††††††††††††† Cost(Basis) ††††††††† ††††††††††††††Fair Market Value†††††

†††††††††††

†††††††††† a.Residence††††††††††††††† ††††††† ____________________ †††††††††† __________________ †††††††††††††††††††††

††††††††††† b.Vacation Home††††† ††††††† ____________________††††††††††† __________________††††††††

 

††††††††††† c.Other††††††††††††††††††††† ††††††† ____________________††††††††††† ___________________

†††††††††††††††††††††††††††† †††††††††††††††††† ††††††††____________________††††††††††† ___________________

††††††††††††††††††††††††††††††††††††††††††††††† ††††††† ____________________††††††††††† ___________________†††††††††

 

†† †††††††††(Please bring all real estate deeds with you to your first conference.)

 

††† 20.†† Personal Property:†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† †††† Fair Market Value††††

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ††††††††††

†††††††† †††a.Automobiles†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ___________________

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ___________________

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ___________________

††††††††††† b.Boats††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ___________________

†††††††††††††††††††††††††††††††††††

††††††††††† c.Antiques and other collectibles††††††††††††††††††††††††††††††††††††††††† ___________________

 

††††††††††† d.Miscellaneous (household effects, etc.)†††††††††††††††††††††††††††† ___________________

†††

 

††† 21.†† Investments and cash: (Please provide documents to indicate legal title of investments

††††††††††† and a detailed schedule if possible.)

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ††††††††††††††† Amount

††††††††††† a.†† Cash and bank accounts†††††††††††††††††††††††††††††††††† ††††††††††††††††††††††††††††††††††††††††††††††††††††

††††††††††††††††††††††† Husband:†††††††††††††††††††††††††††††††††††††††††††† ______________________

 

††††††††††††††††††††††† Wife:†††††††††††††††††††††††††††††††††††††††††††††††††† ______________________

 

††††††††††††††††††††††† Joint††††††††††††††††††††††††††††††††††††††††††††††††††† ______________________

 

b.      Stocks and bonds (including publicly traded securities)

 

††††††††††††††††††††† Husband:†††††††††††††††††††††††††††††††††††††††††††† ______________________

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ††††††††††† Wife:†††††††††††††††††††††††††††††††††††††††††††††††††† ______________________

 

††††††††††††††††††††††† Joint:†††††††††††††††††††††††††††††††††††††††††††††††††† ______________________

 

††††††††††††††††††††††† IRAís (Roth & Regular)†††††††††††††††††††† ______________________

 

23.      Do you have any stock in S-corporations?__________________ or closely held††††††††††††††††††††††††††††

††††††† businesses?______________________________________________________

†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††

††† 24.†† Do you have any interests in partnerships?______________________________

 

DEBTS

 

††† 25.†† Mortgages on residence:______________________________________________

 

††† 26.††† Other real estate mortgages:___________________________________________

 

††† 27.††† Other debts:_______________________________________________________

†††††††††††††

††††††††††††† _________________________________________________________________

 

 


MISCELLANEOUS

 

††††† 28.†† Do either of you have a serious medical condition which will affect the decisions which†††††††††††††††††

††††††††††††† you make with respect to estate planning?††††††††† Yes______†††† No______

 

†††††††††††† a.If yes, briefly describe:________________________________________________

††††††

†††† 29.†† Does either spouse expect to receive substantial gifts or inheritances in the near future?

†††††††††††† Yes_____†† No______†††† (If yes, please attach a sheet that provides specific information.)

 

†††† 30.†† Is either spouse a beneficiary of any trusts?†††† Yes_____†† No_____

†††††††††††† (If yes, please furnish trust documents and a list of assets in each trust.)

 

††† 31.†† Has either of you made taxable gifts?††† Yes_____†† No_____

††††††††††† (If yes, please furnish gift tax returns in connection with such gifts.)

 

††† 32.†† Do you have a safe deposit box?††† Yes_____†† No______

††††††††††† a.If yes, at what location(s)?______________________________________________

 

††† 33.Are there any continuing financial responsibilities as a result of prior marriages?††

†††††††††† Yes______††† No______††† (If yes, please furnish details including relevant documents†††††††††††††††††††

††††††††††† such as property settlement and separation agreements.)

 

††† 34.†† Have you lived in one of the following states during your current marriage?

†††††††††††† Yes______††† No______

 

††††††††††† a.If yes, check applicable states (community property states):

 

†††††††††††††††††††††††††††††††††† Arizona_________††††††††† California____________

†††††††††††††††††††††††††††††† ††††

†††††††††††††††††††††††††††††††††† Idaho___________†††††††††† Louisiana___________

 

†††††††††††††††††††††††††††††††††† Nevada__________††††††††† New Mexico_________

††††††††††

†††††††††††††††††††††††††††††††††† Texas___________††††††††† Washington__________

 

†††††††††††††††††††††††††††††††††† Wisconsin________

 

35.Is there anything else about yourself, your family or your circumstances that you would like

for us to know about you? ___________________________________________________

________________________________________________________________________

________________________________________________________________________

 

________________________________________________________________________