Estate Planning Patrimony Form

ESTATE PLANNING PATRIMONY FORM

RECITALS

WHEREAS, Declarant Name: (the "Declarant") is the lawful owner of certain assets and property to be identified and managed for the purposes of estate planning and orderly patrimonial disposition; and

WHEREAS, the Declarant elects to create a formal record of patrimony and engagement terms with Estate Representative: to govern identification, preservation, and disposition of said patrimony under the terms set forth below; and

WHEREAS, this form records the Declarant's present patrimony, beneficiary designations, and the engagement and payment terms for the Representative's services with the intent that these statements inform wills, trusts, powers of attorney, and related estate-planning instruments.

DECLARANT INFORMATION

SCOPE OF PATRIMONY (ASSET DESCRIPTION)

The Declarant hereby identifies the following categories and descriptions of assets, holdings, and interests that comprise the Declarant's patrimony for estate planning purposes. Declarant affirms that the information provided is accurate to the best of the Declarant's knowledge as of the Date of Declaration:

ITEMIZED ASSET SCHEDULE

Asset 1

Asset 2

Asset 3

BENEFICIARY DESIGNATIONS

TRUSTEE / EXECUTOR / REPRESENTATIVE

Representative Powers (select all that apply):

PAYMENT TERMS

The Declarant agrees to compensate the Representative for estate planning services according to the following terms.

TERM AND TERMINATION

This engagement commences on Start Date: and continues until End Date: unless earlier terminated in accordance with this section.

Either party may terminate this engagement upon written notice delivered not less than days prior to the intended termination date. Termination does not relieve the Declarant of payment obligations for services performed and expenses incurred up to the effective date of termination.

CONFIDENTIALITY

The Representative shall maintain in strict confidence all nonpublic information and documents obtained from the Declarant in connection with this engagement. Such confidential information shall not be disclosed except to the extent required by law or to professional advisors engaged to perform services under this engagement, and only after such advisors agree to be bound by confidentiality obligations substantially similar to those herein. This obligation shall survive termination of the engagement.

GOVERNING LAW

This form and any dispute arising out of its interpretation or performance shall be governed by and construed in accordance with the laws of the Jurisdiction: without regard to conflicts of law principles.

ENTIRE AGREEMENT

This document, together with any attachments and executed schedules, constitutes the entire agreement between the Declarant and the Representative with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, proposals, and communications, whether oral or written. Any amendment or modification must be in writing and signed by both parties.

ACKNOWLEDGMENTS AND CERTIFICATION

The Declarant certifies that the information provided herein is true and correct to the best of the Declarant's knowledge, and acknowledges that this record may be relied upon by counsel, trustees, and other persons acting in accordance with the Declarant's estate plan. The Declarant understands that this form does not itself effectuate transfers of title but is an evidentiary statement of intent and instruction for estate planning purposes.

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