Fill and Sign the Estate Planning Questionnaire and Worksheets Nebraska Form

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 status Single 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 ofcer       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 diferent from estate owner’s)             Business or profession       - 1 - CHILDREN AND GRANDCHILDREN (Designate which children or grandchildren, if any, are adopted, are stepchildren or are children of a prior marriage) Name Birth date Relationship Domicile Name of Spouse                                                                                                                                                                                                                   WHO WILL BENEFIT UNDER WILL Name Address Age Status (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       - 2 - 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) Date Cost Current Mortgages Net Current Date Purchased Improvements Value Description or Address:                                                 Description or Address:                                                 Description or Address:                                                 Description or Address:                                                 Description or Address:                                                 Description or Address:                                                 B. STOCKS AND BONDS Name Type of Business Date Acquired Original Cost # of Shares Current Market Value                                     Address:                                           Address:                                           Address:                                           Address:                                           Address:       C. U.S. government bonds (e.g., Series “E” or “EE” bonds) Payable on Death to Face Value Issue Date Current Value                                                                         - 3 - FINANCIAL INFORMATION D. CASH Name & Address Of Bank Account Number Checking or Savings Trust Account Benefciary                                                                                                                                                                                                 E. MORTGAGES AND PROMISSORY NOTES Name of Mortgagor or Creditor Unpaid Face Value Repayment Balance Interest Terms Rate                                                                                                                                                                                                                         F. LIFE INSURANCE Company Policy Number Name of Insured Current Benefciary Date                               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 APPOINTMENT Instrument conferring Power created Date power subject to power Value of property                                                                         H. ANNUITIES AND DEATH BENEFITS (Include Keogh plans and IRAs) (get copies of contracts, plans, etc.) - 4 - FINANCIAL INFORMATION Annuity or Lump sum Type of Plan Estate Designated Payment Owner’s Benefciary Approx. Contribution Value                                                                                                                                                                                                                   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 (Proft Sharing, Pension, IRA, 401(k)s, etc.)                                     Furniture & furnishings in home                         Furniture & furnishings elsewhere                         Collectibles                         Jewelry                         - 5 - ASSETS: DESCRIPTION OF ALL ASSETS (To avoid confusion at a later date, describe each item as clearly as possible.) Current Fair Market Value 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 Payment Current 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                                                 Total Debts and Liabilities             - 6 - LIABILITIES AND (To avoid confusion at a later date, describe each item as clearly as possible. ) Monthly Payment Current Amount Owed Summary of Assets and Liabilities Total Assets       Less Total Liabilities       Net Worth       Retirement Accounts Account Number Current Fair Market Value Husband Accounts:                                                                         Wife Accounts:                                                                         Income of Husband (Monthly) Monthly Yearly Salary                   Dividends                   Rental Income                   Notes Receivable                   Bonuses                   Business                   Other                   Total Income             Income of Wife Monthly Yearly Salary                   Dividends                   Rental Income                   Notes Receivable                   Business                   Bonuses                   Other                   Total Income             - 7 - 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. Na me of Person to Receive Property Description of Property                                                                                                                                     Describe any other last wishes       - 8 - Addendum (For Additional Information)                                                                                                                                           - 9 -