Fill and Sign the Masters Esq Form

Randy K. Masters, Esq. Virginia Legal Services, PLC 300 Arboretum Place, Suite 140 Richmond, VA 23236(804) 323-7700 CONFIDENTIAL CLIENT INFORMATION FOR ESTATE PLANNING 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. ARE THESE CHILDREN FROM THIS MARRIAGE? [] YES [] NO IF NO, PLEASE EXPLAIN: _____________________________________ C. ARE THERE SPECIAL NEEDS FOR ANY CHILD? [] YES [] NO IF YES, PLEASE EXPLAIN: ____________________________________ III. KEY PEOPLE IN YOUR ESTATE PLAN: A. EXECUTORS OF WILLS: FIRST CHOICE: Do you wish that the other spouse serve as your first choice for Executor? Yes ________ No, my first choice shall be: _________________________________________________________________ ADDRESS__________________________________________________________2ND CHOICE (if any)_______________________________________________ ADDRESS__________________________________________________________ 3RD CHOICE (if any)_______________________________________ADDRESS__________________________________________________________ B. TRUSTEES OF REVOCABLE LIVING TRUSTS: ORIGINAL TRUSTEES SHALL BE YOU AND YOUR SPOUSE 1ST SUCCESSOR ___________________________________________________ 2ND SUCCESSOR ___________________________________________________ C. GUARDIANS FOR MINOR CHILDREN (if any): FIRST ______________________ Address:________________________________ SECOND _____________________ Address:________________________________ D. AGENT FOR YOUR FINANCIAL DURABLE POWER OF ATTORNEY 1st CHOICE [Spouse, or other choice?]__________________ 2nd CHOICE___________________________ 3rd CHOICE___________________________ D. AGENT FOR YOUR HEALTH CARE DURABLE POWER OF ATTORNEY 1st CHOICE [Spouse, or other choice?]__________________ 2nd CHOICE___________________________ 3rd CHOICE___________________________ IV. BENEFICIARIES OF TRUST ASSETS: Name Percentage of trust Relationship _______________________ ___________________ ______________ _______________________ ___________________ ______________ _______________________ ___________________ ______________ _______________________ ___________________ ______________ ____________________ _________________ ____________ V. SPECIFIC GIFTS (for example, if you want a certain person to receive a set amount of money, real property, or other asset directly, before the trust assets are distributed. Remember, though, that the Virginia Code allows you to put a “Memorandum” with your will, directing your Executor to distribute certain articles of personal property to whomever you choose. This way, you may amend the Memorandum whenever you wish, without having to amend the Will.) Property to be gifted Full name of beneficiary 1. 2.3.4. SUMMARY OF ESTATE ASSETS CURRENT VALUE 1. Real Estate _____________ 2. Closely-held corp. stock _____________ 3. Listed securities _____________ 4. Cash _____________ 5. Mortgages and promissory notes _____________ 6. Life insurance proceeds to heirs _____________ 7. Jointly-owned property _____________ 8. 50% of value of property owned jointly w/spouse _____________ 9. Miscellaneous property interests _____________ 10. General power of appointment _____________ 11. Annuities, death benefits _____________ 12. Gift tax paid on gifts within last 3 years _____________ TOTAL:__________________