Form married

Address

CHILDREN
USE FULL LEGAL NAME.USE "JT" IF BOTH SPOUSES ARE THE PARENTS ,"H" IF HUSBAND IS THE PARENT,"S" IF A SINGLE PARENT

Your Concerns
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)

Description

	Wife	Husband
Desire to get affairs in order and create a comprehensive plan to manage affairs in case of death or disability.
Providing for and protecting a spouse.
Providing for and protecting children.
Providing for and protecting grandchildren.
Providing for charities at the time of death.
Plan for the transfer and survival of a family business.
Avoiding or reducing your estate taxes.
Avoiding probate.
Reduce administration costs at time of your death.
Avoiding a conservatorship (“living probate”) in case of a disability.
Avoiding will contests or other disputes upon death.
Protecting assets from lawsuits or creditors.
Preserving the privacy of affairs in case of disability or at time of death from business competitors, predators, dishonest persons and curiosity seekers.
Plan for a child with disabilities or special needs, such as medical or learning disabilities.
Protecting children’s inheritance from the possibility of failed marriages.
Protect children’s inheritance in the event of a surviving spouse’s remarriage.
Provide that your death shall not be unnecessarily prolonged by artificial means or measures.

(Please check “Yes” or “No” for your answer)

	YES	NO
Are you (or your spouse) making payments pursuant to a divorce or property settlement order? Please furnish a copy
If married, have you and your spouse signed a pre- or post-marriage contract? Please furnish a copy
Have you (or your spouse) been widowed? If a federal estate tax return or a state death tax return was filed, please furnish a copy
Have you (or your spouse) ever filed federal or state gift tax returns?
Please furnish copies of these returns
Have you (or your spouse) completed previous will, trust, or estate planning? Please furnish copies of these documents
Do you support any charitable organizations now that you wish to make provisions for at the time of your death? If so, please explain below.
Are there any other charitable organizations you wish to make provisions for at the time of your death? If so, please explain below.
Are you (or your spouse) currently the beneficiary of anyone else’s trust? If so, please explain below.
Do any of your children have special educational, medical, or physical needs?

Are you (or your spouse) receiving Social Security, disability, or other governmental benefits? Describe here
Additional Information

Real Property
TYPE: Any interest in real estate including your family residence, vacation home, timeshare, vacant land, etc.

	General Description and/or Address	Owner	Market Value	Loan Balance	Total
1
2
3
4
5

Bank Accounts
TYPE: Checking Account "CA", Savings Account “SA”, Certificates of Deposit “CD”, Money Market “MM”. Please do not include your IRA or 401(k) information here, as you will be asked in another section. (indicate type below).

	Name of Institution and account number	Type	Owner	Amount	Total
1
2
3
4
5

Note: 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)

If you hold investment accounts, please be sure to provide current statements for our team's review.

ADDITIONAL INFORMATION:

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.
Type

	Describe the type of plan	The plan name	The current value of the plan	Any other pertinent information.	Total
1
2
3
4

Other Assets
TYPE: Other property is any property that you have that does not fit into any listed category.

Business Interests (Owned By You or Spouse
Name of Business
Location of Business
Product or Service
Form of Business Organization

Partnership Sole Proprietorship C Corp S Corp LLC
Your Share of Business
Your Position
Do you have any other partners? If yes, please select number.
Do you have a Buy/Sell Agreement in place?
Total Business Value
Miscellaneous
Please add any additional worth (ie. Valuable personal property, money owed to you, expected inheritances, annuities, any other special facotrs which may affect your situation)
Should be Empty:

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Part II