Fill and Sign the Date of Gift Value Form

- 1 - ESTATE PLANNING QUESTIONNAIRE FOR: DATE: PERSONAL INFORMATION Name Birth date U.S. Citizen Principal Residence Any other Domicile: Domicile in community property states(s) (if ever): Birthplace: Social Security Number Dates of such domicile Community property acquired Business or profession Still:Active Retired Current marital statusSingle Married Widowed Divorced Prior Marriages (if any) Name of former spouse(s) Name and ages of children of prior marriages How and when prior marriage(s) ended: (if divorce, get copies of any agreements and decrees) Principal bank(s) Personal Trust officer Location of safe deposit box(es) Accountant Investment advisor Insurance advisor SPOUSE Name Date and place of birth U.S. Citizen Social Security Number Date and place of marriage Legally separated When and where Residence (if different from estate owner’s) Business or profession - 2 - CHILDREN AND GRANDCHILDREN (Designate which children or grandchildren, if any, are adopted, are stepchildren or are children of a prior marriage)NameBirth dateRelationshipDomicileName of Spouse WHO WILL BENEFIT UNDER WILL NameAddressAgeStatus (e.g. child, friend, employee) FIDUCIARIES Executor(s)Name Address Successor(s) Name Address Trustee(s)Name Address Successor(s) Name Address Children’s Guardian(s)Name Address Successor(s) Name Address - 3 - GIFTS MADE DURING LIFE (obtain copies of instruments of transfer and gift tax returns) Donee Date of Gift Type of property given Date of gift value Outright or trust gift Was gift split with spouse? If yes, who paid gift tax? FINANCIAL INFORMATION A. REAL ESTATE (including condominium, apartment) DateCost Current MortgagesNet CurrentDate Purchased Improvements Value Description or Address: Description or Address: Description or Address: Description or Address: Description or Address: Description or Address: B. STOCKS AND BONDSNameType of BusinessDate AcquiredOriginal Cost# of SharesCurrent Market Value Address: Address: Address: Address: Address: C. U.S. government bonds (e.g., Series “E” or “EE” bonds)Payable onDeath toFace ValueIssue DateCurrent Value - 4 - FINANCIAL INFORMATION D. CASHName & AddressOf BankAccount NumberChecking or SavingsTrust Account Beneficiary E. MORTGAGES AND PROMISSORY NOTESName of Mortgagor or CreditorUnpaid Face ValueRepayment BalanceInterest Terms Rate F. LIFE INSURANCE Company Policy NumberName of InsuredCurrent BeneficiaryDate Face Amount of Policy: Death/Loan Value: Face Amount of Policy: Death/Loan Value: Face Amount of Policy: Death/Loan Value: Face Amount of Policy: Death/Loan Value: Face Amount of Policy: Death/Loan Value: G. GENERAL POWERS OF APPOINTMENTInstrument conferring Power createdDate power subject to powerValue of property - 5 - FINANCIAL INFORMATION H. ANNUITIES AND DEATH BENEFITS (Include Keogh plans and IRAs) (get copies of contracts, plans, etc.)Annuity or Lump sum Type of PlanEstate Designated PaymentOwner’s BeneficiaryApprox. ContributionValue ASSETS: DESCRIPTION OF ALL ASSETS(To avoid confusion at a later date, describe each item as clearly as possible.) Current Fair Market Value Cash (on hand) Cash (in banks/credit unions)(From List Above) Other Cash: Stocks/Bonds (From List Above) Other Stocks and Bonds Notes (money owed to you in writing) Money owed to you (not evidenced by a note) Real estate: (From List Above) (Other) Business Interests Automobiles Boats Other vehicles Retirement plans (Profit Sharing, Pension, IRA, 401(k)s, etc.) Furniture & furnishings in home Furniture & furnishings elsewhere - 6 - ASSETS: DESCRIPTION OF ALL ASSETS (To avoid confusion at a later date, describe each item as clearly as possible.) Current Fair Market Value Collectibles Jewelry Life insurance (cash surrender value) Sporting and entertainment (T.V., stereo, etc.) equipment Other assets Total Assets LIABILITIES AND (To avoid confusion at a later date, describe each item as clearly as possible. ) Monthly PaymentCurrent Amount Owed Mortgages on real estate: (Home) (Other) Charge/credit card accounts Auto loan Auto loan Bank/credit union loans Money you owe (not evidenced by a note) Judgments Other - 7 - LIABILITIES AND (To avoid confusion at a later date, describe each item as clearly as possible. ) Monthly PaymentCurrent Amount Owed Total Debts and Liabilities Summary of Assets and LiabilitiesTotal Assets Less Total Liabilities Net Worth Retirement Accounts Account Number Current Fair Market Value Husband Accounts: Wife Accounts: Income of Husband (Monthly) MonthlyYearly Salary Dividends Rental Income Notes Receivable Bonuses Business Other Total Income Income of Wife MonthlyYearly Salary Dividends Rental Income Notes Receivable Business Bonuses Other Total Income - 8 - - 9 - Worksheets (Who will receive your property) Do you want all property to go to spouse, or if spouse not alive to your children?Yes If no please continue. If yes, stop.Who is to receive home? Describe who you desire to receive other property. Name of Person to Receive PropertyDescription of Property Describe any other last wishes - 10 - Addendum (For Additional Information)