ESTATE PLANNING PERSONAL DATA SHEET

(MARRIED)

 

Date                                   Tel. Home                                      Tel. Bus.                                 

This form is extremely important.  Your accuracy and completeness in responding will help me best represent you.  Bring this information with you to the appointment.  Please list names as they would appear on legal documents.

 

 

PERSONAL DATA

 

(Husband)                                                                              (Wife)

Full Name                                                                Full Name                                                   

                     (print name as shown on your checks)                                    (print name as shown on your checks)

 

Address                                                                                                                                  

 

                                                                                                               Zip                         

           

(Husband)                                                                            (Wife)

Birth Date                                                                          Birth Date                                                    

 

Social Security Number                                                       Social Security Number                                 

 

U.S. Citizen?  Yes                    No                              U.S. Citizen?  Yes                     No             

 

Annual Income                                                        Annual Income                                            

 

 

REFERRAL

 

By whom were you referred to this office?

 

Name                                                                                                                                     

 

Address                                                                                                                                   

 

DISPOSITIVE INTENTIONS

 

1.  Do you wish to provide primarily for your spouse and secondarily for your children? 

            Yes                                No                        

 

            Do you wish to treat all of your children equally?  Yes                   No                 

 

            After your spouse's death, at what age do you want distribution to  your children:

            (e.g. a typical plan provides for 1/3 at age 25, 1/3 at age 30 and 1/3 at age 35)

 

            Your choice of age:                                                                                                       

 

2.         Do you want to leave a specific amount of money or a percentage of your estate to your              grandchildren?      Yes                     No                

 

            If so, do you wish to treat them equally?   Yes                                No                 

 

            If so, how much?                                                                                                           

 

            Your choice of age:                                                                                                        

 

            For what purpose?                                                                                                         

 

            Beneficiary:                                                                                                                   

 

3.  Do you want to leave a specific amount of money or other assets to any charity?

            Yes                    No                 

 

            If so, how much?                                                                                                           

 

            Name and Address of Charity                                                                                          

 

                                                                                                                                               

 

4.         If you have no children, who do you wish to provide for in your Will?

 

                                                                                                                                               

 

                                                                                                                                                

 

 

EXECUTOR

 

Who do you wish to serve as your Executor?

 

First Choice                                                                                                                            

 

Second Choice                                                                                                                         

TRUSTEE

 

Who do you want to serve as your Trustee?

 

First Choice                                                                                                                            

 

Second Choice                                                                                                                         

 

 

GUARDIAN

 

Who do you want to act as Guardian of your minor children?

 

First Choice                                                                                                                            

 

Second Choice                                                                                                                         

 

 

LIVING WILL

 

Do you want your Living Will to provide for withdrawal of artificial food and fluid? 

Yes                   No                 

 

Do you want to donate your eyes or organs?  Yes                No             

 

Do you want your Health Care Representative to consult with any other person prior to acting? 

Yes                 No             

 

Name of proposed Health Care Agent (usually family member or friend)                                        

 

                                                                                                                                             

Address of proposed Health Care Agent                                                                                      

 

                                                                                                               Zip                         

 

Name of proposed Alternate Health Care Agent                                                                           

 

Address of proposed Alternate Health Care Agent                                                                        

 

                                                                                                               Zip                         

 

What is the name, address and telephone number of your primary care physician?

 

                                                                                                                                             

 

                                                                                                                                            

 

 

POWER OF ATTORNEY

 

Name of proposed Financial Agent (usually family member or friend)                                            

 

                                                                                                                                            

 

Address of proposed Financial Agent                                                                                         

 

                                                                                                               Zip                         

 

Name of proposed Alternate Financial Agent                                                                               

 

Address of proposed Alternate Financial Agent                                                                            

 

                                                                                                                Zip                        

 

 

MISCELLANEOUS

 

Do you have any other legal issues which I should be aware of?  Yes                          No              

 

If yes, please explain:                                                                                                               

 

                                                                                                                                            

 

                                                                                                                                             

 

                                                                                                                                            

 

                                                                                                                                             

 

CHILDREN (if applicable)

 

CHILD'S NAME	ADDRESS WITH ZIP CODE	DATE OF BIRTH

 

GRANDCHILDREN (if applicable)

 

GRANDCHILD'S NAME	ADDRESS WITH ZIP CODE	DATE OF BIRTH