Estate Planning Form

Personal Information

Name

Date of Birth Social Security Number

Birthplace U.S. citizen? YES NO

E-mail

Employer Work Phone

Spouse's Name

Date of Birth Social Security Number

Birthplace U.S. citizen? YES NO

E-mail

Employer Work Phone

Home Address

City State County

Home Telephone

Safe Deposit Box Location and Access

Prenuptial Agreement? YES NO

Prior Marriage of Either Spouse
(Name of spouse from prior marriage)

**CHILDREN**
Child's Name	Date of Birth	Occupation	Marital Status	Child of Husband Wife or Both

**YOUR PARENTS**
Name	Date of Birth	Living/ Deceased	Birthplace
		L D
		L D

**SPOUSE'S PARENTS**
Name	Date of Birth	Living/ Deceased	Birthplace
		L D
		L D

**YOUR CLOSE RELATIVES**
Name	Relationship	Date of Birth	City of Residence

**SPOUSE'S CLOSE RELATIVES**
Name	Relationship	Date of Birth	City of Residence

Identification of Selected Fiduciaries

Personal Representative (Executor), First Choice(s)
Alternate(s)
Trustee, First Choice(s)
Alternate(s)
Guardian for Minor Children, First Choice(s)
Alternate(s)
Agent - General Durable Power of Attorney (Property),First Choice(s)
Alternate(s)
Agent - Advance Directive (Health Care), First Choice(s)
Alternate(s)
Physician(s) to Determine Capacity (Optional)

Asset Information

Please list approximate value of assets.

If unmarried, leave the husband and wife columns blank and list value of assets in "Total" column.
If married, list value of assets owned separately by husband in the "Husband" column and assets owned separately by wife in the "Wife" column.
Where an asset is owned jointly by husband and wife with right of survivorship, list value of that asset in the "Joint" column.
If any asset is owned jointly by husband and wife as tenants in common without any right of survivorship, list 50% of its approximate value in the "Husband" column and 50% in the "Wife" column. If either spouse owns any asset as a tenant in common with any other person(s), list only the spouse's share of the approximate value of that asset in that spouse's column.

**CASH AND SAVINGS**
Assets	Husband	Wife	Joint	Total
Checking
Money Market
Savings
Certificate of Deposit


Total Cash & Savings

**MARKETABLE SECURITIES**
	Husband	Wife	Joint	Total
Stocks
Bonds
Mutual Funds


Total Marketable Securities

**PERSONAL RESIDENCE**
	Husband	Wife	Joint	Total
Primary Residence Less Mortgage Net Equity
Other Residence Less Mortgage Net Equity
Total Personal Residence

**INVESTMENT REAL ESTATE**
Assets	Husband	Wife	Joint	Total



Total Investment Real Estate

**BUSINESS INTERESTS**
Assets	Husband	Wife	Joint	Total



Total Business Interests

**OTHER ASSETS**
Assets	Husband	Wife	Joint	Total
Installment Obligations


Total Other Assets

**PERSONAL PROPERTY**
Assets	Husband	Wife	Joint	Total
Household furniture
Jewelry
Motor vehicle
Antiques and collectibles
Total Personal Property

**RETIREMENT PLANS**
Assets	Husband	Wife	Total
IRA
401(k) or 403(b)


Total Retirement Plans

TOTAL ASSETS

**LIABILITIES**
Liabilities	Husband	Wife	Joint	Total



Total Liabilities

**TOTAL NET WORTH**
	Total Assets	Minus Liabilities	Equals Total Net Worth
Husband
Wife
Joint
Total Net Worth

**LIFE INSURANCE**
Life Insurance	Husband (face value)	Wife (face value)	Cash Value	Total
Employer Provided Group Life
Owned by Husband on His Life
Owned by Wife on Her Life
Owned by Husband on Wife's Life
Owned by Wife on Husband's Life
Total

	Total Net Worth	Plus Face Value of Life Insurance	Equals Grand Total
Husband
Wife
Joint
Grand Total

Does either spouse own any property jointly with right of survivorship with
any person other than the other spouse? YES NO
If yes, please describe below. (Do not list this property in the above list of assets.)

Have you or your spouse ever made a gift to any one person in excess of $3,000
per year before 1982, or $10,000 per year after 1981? YES NO
If yes, please describe below. If you need more room, please write directly on print out.
	Gift #1	Gift #2
Gift From
Gift To
Date
Was Gift Tax Return Filed?	Yes No	Yes No
Property Given
Value of Property

Does either spouse expect to receive any relatively large inheritances or gifts
in the future? YES NO
If yes, please describe below.

Financial Advisor's Name Ph:

Company

Accountant's Name Ph:

Company

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