Fill and Sign the Estate Questionnaire Form

ESTATE PLANNING QUESTIONNAIRE 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 (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 (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             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 - 7 -                                                                                                                                     Describe any other last wishes       - 8 - LEGAL DOCUMENTS Document State Where Executed Location of Original Date Executed Last Will and Testament                   Durable Power of Attorney                   Living Will/Health Care Proxy                   Living Trust                   Who are the Trustees of your trust?       Is your trust fully funded? Yes No Are the assets properly allocated between the trusts? Yes No Does your trust specify a test to determine your disability? Yes No Does your trust address your spouse’s remarriage? Yes No Does your trust contain Estate Tax planning? Yes No Have the benefciaries been changed on your retirement assets? Yes No Is there a method to remove a trustee if necessary? Yes No Do you own any joint tenancy property? Yes No Does your trust contain in-home health care language? Yes No Have the benefciaries been changed on your life insurance? Yes No Are family members successor trustees? Yes No Does your trust give instruction on your care and the care of your loved ones during your disability? Yes No Does your trust provide creditor protection for assets passing to your surviving spouse? Yes No Does your trust address income tax planning? Yes No Does your trust allow for continued gifting during your disability? Yes No Does your trust protect your children’s inheritance from a divorcing spouse? Yes No Does your trust provide creditor protection for your children’s inheritance? Yes No - 9 - What is the private pay rate of the nursing home or assisted living facility (ALF) where the client or client’s spouse is staying or will be staying? Daily       Monthly       List any other expenses that are anticipated at the nursing home or ALF       What is the monthly cost of Medicare Supplement Insurance for client?       For client’s spouse       If the client’s spouse is, or going to be, in a nursing home or ALF, how much income will be needed monthly to pay ongoing expenses of the well spouse?       LEGAL AND FINANCIAL DECISIONS If you were unable to carry out your legal and fnancial business, who would you want to take care of your legal, business, personal, and fnancial afairs? First Choice: Name       Address       Phone       Second Choice Name       Address       Phone       If you were in the hospital and unable to make decisions for yourself, with whom would you want your doctor to consult with about your care (that is, to be your health care advocate)? First Choice: Name       Address       Phone       Second Choice Name       Address       Phone       Does any potential benefciary have special educational, medical or physical needs, or receive governmental benefts? Yes No Does any potential benefciary have any potential problems with drug or alcohol abuse? Yes No Are you concerned with any potential benefciary’s ability to handle/manage money? Yes No Are you concerned with your children’s ability to get along with one another? Yes No Are their problems/concerns relative to your relationship with your children (or spouse’s children)? Yes No Have any of your children received a divorce? Yes No Do you expect to inherit money? Yes No If yes, describe:       Addendum (For Additional Information)       - 10 -