Fill and Sign the Essential Document Locator Form

Your Personal Information NAME ____________________________________ BIRTHDATE _____________ SPOUSE __________________________________ BIRTHDATE _____________ HOME ADDRESS ____________________________________________________ CITY ___________________________ STATE ___________ ZIP __________ HOME TELEPHONE (       )       WORK PLACE- HIS __________________________________________________ ADDRESS__________________________________________________________ WORK TELEPHONE (       )       WORK PLACE- HER __________________________________________________ ADDRESS __________________________________________________________ WORK TELEPHONE (       )       SOCIAL SECURITY #: YOU __________________ SPOUSE ________________ MARITAL STATUS: [] MARRIED [] SINGLE [] WIDOW(ER) [] DIVORCED [] LEGALLY SEPARATED UNITED STATES CITIZEN: YOU: [] YES [] NO; SPOUSE [] YES [] NO I. CHILDREN: (indicate if adopted) 1. NAME ________________________________ BIRTHDATE ______________ CHILD'S SPOUSE _________________________ MINOR CHILDREN? []YES []NO CITY AND STATE _________________________ 2. NAME ________________________________ BIRTHDATE_______________ CHILD'S SPOUSE _________________________ MINOR CHILDREN? []YES []NO CITY AND STATE _________________________ 3. NAME ________________________________ BIRTHDATE______________ CHILD'S SPOUSE _________________________ MINOR CHILDREN? []YES []NO CITY AND STATE _________________________ 4. NAME ________________________________ BIRTHDATE______________ CHILD'S SPOUSE _________________________ MINOR CHILDREN? []YES []NO CITY AND STATE _________________________ 5. NAME ________________________________ BIRTHDATE______________ CHILD'S SPOUSE _________________________ MINOR CHILDREN? []YES []NO CITY AND STATE _________________________ II. BACKGROUND INFORMATION: A. PREVIOUS MARRIAGES: FORMER SPOUSE: __________________________________ DATE & PLACE OF MARRIAGE: __________________________________ HOW TERMINATED: __________________________________ DATE: __________________________________ B. DIVORCE OBLIGATIONS (PAY/RECEIVE): CHILD SUPPORT: __________________________________ ALIMONY: __________________________________ LIFE INSURANCE: __________________________________ OTHER TERMS: __________________________________ C. ARE THESE CHILDREN FROM THIS MARRIAGE? [] YES [] NO IF NO, PLEASE EXPLAIN: _____________________________________ D. ARE THERE SPECIAL NEEDS FOR ANY CHILD? [] YES [] NO IF YES, PLEASE EXPLAIN: ____________________________________ E. DO YOU SUPPORT OR EXPECT TO SUPPORT ANYONE ELSE SUCH AS A PARENT OR OTHER PERSON? [] YES [] NO IF YES, PLEASE EXPLAIN: ____________________________________ F. MILITARY SERVICE: (BRANCH, RANK, SERIAL #, DATES): _________ ____________________________________________________________ G. DESCRIBE ANY SIGNIFICANT HEALTH PROBLEMS: __________________ ____________________________________________________________ H. NAME & ADDRESS OF PHYSICIAN: _______________________________ III. KEY PEOPLE IN YOUR ESTATE PLAN: A. EXECUTORS OF WILLS: FIRST Spouse [ ] Other ADDRESS__________________________________________________________ ALTERNATE_____________________________________________________ ___ ADDRESS__________________________________________________________ SECOND ALTERNATE ________________________________________________ ADDRESS__________________________________________________________ B. TRUSTEES OF TESTAMENTARY OR REVOCABLE LIVING TRUSTS: ORIGINAL Spouse(s) [ ] Other 1ST SUCCESSOR ___________________________________________________ 2ND SUCCESSOR ___________________________________________________ 3RD SUCCESSOR ___________________________________________________ C. GUARDIANS FOR MINOR CHILDREN: FIRST ___________________________________________________________ SECOND __________________________________________________________ THIRD ___________________________________________________________ ESTATE PLANNING DATA SHEET INFORMATION FOR YOUR EXECUTOR(S) PART II I. INVENTORY OF ASSETS (Please complete with full information): A. REAL ESTATE (Including condominium apartment) DATE COST PLUS CURRENT MORTGAGE NET CURRENT DESCRIPTION PURCHASED IMPROVEMENTS VALUE PAYABLE VALUE B. BUSINESSES IN WHICH YOU HAVE AN INTEREST: (Put additional businesses on back of page) *TYPE: C -CORPORATION S -S CORPORATION SP -SOLE PROPRIETORSHIP P -PARTNERSHIP PC -PROFESSIONAL CORPORATION 1. NAME OF BUSINESS: ______________________________________ ________ WHAT DOES BUSINESS DO?__________________________________________ *TYPE SHAREHOLDERS/PARTNERS OWNERSHIP VALUE ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ WHO WILL CONTINUE THE BUSINESS UPON RETIREMENT OR DEATH? _____________________________________________________________________ DO YOU HAVE BUY-SELL AGREEMENTS FOR THE BUSINESS? _____________________________________________________________________ DO YOU HAVE KEY-MAN AND/OR DISABILITY INSURANCE? _____________________________________________________________________ C. STOCKS AND BONDS 1. Listed Securities (stocks and bonds) NO. OF SHARES DATE ORIGINAL CURRENT DESCRIPTION OR FACE VALUE ACQUIRED COST MARKET VALUE 2. U.S. Government Bonds (e.g., Series "E" or "EE" bonds) PAYABLE ON FACE VALUE DEATH TO ISSUE DATE CURRENT VALUE D. 1. CASH NAME & ADDRESS ACCOUNT CHECKING OR TRUST ACCOUNT CURRENT OF BANK NUMBER SAVINGS BENEFICIARY BALANCE 2. MORTGAGES and PROMISSORY NOTES NAME OF MORTGAGEE UNPAID REPAYMENT INTEREST OR CREDITOR FACE VALUE BALANCE TERMS RATE E. LIFE INSURANCE COMPANY:_________________________ POLICY NAME OF NAME OF TRANSFERRED, CURRENT FACE DEATH NUMBER INSURED OWNER DATE BENEFICIARY VALUE LOAN VALUE F. ANNUITIES AND DEATH BENEFITS (Include Keogh plans and IRAs) ANNUITY OR DESIGNATED ESTATE OWNER'S APPROX. TYPE OF PLAN LUMP SUM PAYOUT BENEFICIARY CONTRIBUTION VALUE