Print and complete. Date Completed: ____________________ Please bring to your appointment, along with current estate plan, financial statement or last tax return
Legal Name _____________________________ __________________________ (name most often used to title property and accounts) Birth date US Citizen? Home Address Home Telephone Business Telephone ______________ County of Residence Employer Position __________________________ E-mail Address Income, for all sources, last tax was $ Married Divorced Widowed Single? Date of Marriage
Name of Spouse/Partner_________________________________________________ (name most often used to title property and accounts) Birth date _____________________ US Citizen? Home Address Home Telephone ___________ Business Telephone _______________ County of Residence Employer Position_________________________________ Address E-mail Address Income, all sources, last tax year was $ Children and/OR other FAMILY MEMBERS (Use full legal name. Use “JT” if both spouses are the parents, “H” if husband is the parent, “W” if wife is the parent, “S” if a single parent.) Name Birth date Parent or Relationship Special challenges, e.g. addictions, learning disabilities, etc.?
Name Birth date Parent or Relationship
Special challenges, e.g. addictions, learning disabilities, etc.?
Name Birth date Parent or Relationship
Special challenges, e.g. addictions, learning disabilities, etc.?
Please rate the following as to how important they are to you: (H high concern, S some concerned, L low concern, N/A no concern or not applicable
Other Concerns? Important family questions
Any thing else we should know about?
Provide asset, value and ownership
real property TYPE: Any interest in real estate including your family residence, vacation home, time share, vacant land, etc.
Personal effects TYPE: List separately only major personal effects such as, jewelry, collections, antiques, furs, and all other valuable non-business personal property (indicate type below and give a lump sum value for miscellaneous, less valuable items.).
Automobiles, boats and RVs TYPE: For each motor vehicle, boat, RV, etc. please list the following: description, how titled, market value and encumbrance:
Bank & Savings accounts TYPE: Checking Account “CA”, Savings Account “SA”, Certificates of Deposit “CD”, Money Market “MM” (indicate type below). Do not include IRA’s or 401(k)’s here Name of Institution Type Owner Amount
If Account is in your name (or your spouse’s name) for the benefit of a minor, please specify and give minor’s name. Stocks and bonds TYPE: List any and all stocks and bonds you own. If held in a brokerage account, lump them together under each account. (indicate type below)
LIFE INSURANCE and
ANNUITIES
TYPE: Term, whole life, split dollar, group life, annuity. ADDITIONAL INFORMATION: Insurance company, type, face amount (death benefit), whose life is insured, who owns the policy, the current beneficiaries, who pays the premium, and who is the life insurance agent.
Total Retirement plans TYPE: Pension (P), Profit Sharing (PS), H.R. 10, IRA, SEP, 401(K). ADDITIONAL INFORMATION: Describe the type of plan, the plan name, the current value of the plan, and any other pertinent information.
Business interests TYPE: General and Limited Partnerships, Sole Proprietorships, privately owned corporations, professional corporations, oil interests, farm and ranch interests. ADDITIONAL INFORMATION: Give a description of the interests, who has the interest, your ownership in the interests, and the estimated value of the interests.
Money owed to you TYPE: Mortgages or promissory notes payable to you,
or other moneys owed to you.
Anticipated inheritance, gift, or LAWSUIT JUDGMENT TYPE: Gifts or inheritances that you expect to receive at some time in the future; or moneys that you anticipate receiving through a judgment in a lawsuit. Describe in appropriate detail.
Other assets TYPE: Other property is any property that you have that does not fit into any listed category.
* Joint Property values enter 1/2 in husband’s column and 1/2 in wife’s column.
OTHER ITEMS TO INCLUDE OR DISCUSS: Obviously your estate plan should address all your hopes, fears and wishes please list any other items you want included or want to discuss: December 2010 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||