Estate Planning Worksheet – Single Download Form step 1 1) PERSONAL INFORMATION Name Email Telephone: (H) (O) Address Your name SS # Date of Birth County of Residence Are you a U. S. Citizen Estimated Earned Income Estimated Investment Income Previous Marriages: Children: Name of Child One Parents Date of Birth Telephone Child's Spouse Address Child's Children (name/age) Name of Child Two Parents Date of Birth Telephone Child's Spouse Address Child's Children (name/age) Name of Child Three Parents Date of Birth Telephone Child's Spouse Address Child's Children (name/age) Name of Child Four Parents Date of Birth Telephone Child's Spouse Address Child's Children (name/age) Your Parents Father Age Address Is father financially dependent upon you? Mother Age Address Is mother financially dependent upon you? Next step 2 2) ASSETS AND LIABILITIES Real Estate Address County Description Fair Market Value Mortgage Amount How is title held? Tax Map #(on tax bill) Address County Description Fair Market Value Mortgage Amount How is title held? Tax Map #(on tax bill) Address County Description Fair Market Value Mortgage Amount How is title held? Tax Map #(on tax bill) Address County Description Fair Market Value Mortgage Amount How is title held? Tax Map #(on tax bill) Your Insurance: Company and Policy # Owner Beneficiary Death Benefit Cash Value Loans on Policy What type of policy is this (term, whole life, or universal policy)? Company and Policy # Owner Beneficiary Death Benefit Cash Value Loans on Policy What type of policy is this (term, whole life, or universal policy)? Company and Policy # Owner Beneficiary Death Benefit Cash Value Loans on Policy What type of policy is this (term, whole life, or universal policy)? Your Retirement Plans and IRA's: What type of plan is this (IRA, profit sharing, pension, 401(k), non-qualified deferred comp)? Amount of Benefit Beneficiary What type of plan is this (IRA, profit sharing, pension, 401(k), non-qualified deferred comp)? Amount of Benefit Beneficiary Your Brokerage Accounts Brokerage Company Account Number Fair Market Value How is this account titled? Brokerage Company Account Number Fair Market Value How is this account titled? Brokerage Company Account Number Fair Market Value How is this account titled? Please describe any other stocks, bonds, or annuities that you own Bank Accounts and Certificates of Deposit Bank Account or CD Number Name on Account Balance Type of account Bank Account or CD Number Name on Account Balance Type of account Bank Account or CD Number Name on Account Balance Type of account Bank Account or CD Number Name on Account Balance Type of account Business Interests Do you own any interest in any closely held business, professional practice, partnership, limited liability company or sole proprietorship? Please describe the nature of your interest and provide your estimate of the fair market value of your interest? If the business is incorporated is it a subchapter S Corporation? Is there a buy-sell or business continuation agreement? Please estimate the value of miscellaneous personal property including automobiles, boats, jewelry, antiques, art, tools, etc. Does anyone owe you money? If so, please describe the nature of the loan arrangement and outstanding balance. Please list any liabilities other than real estate mortgages that are listed under Item A. Back Next step 3 3) MISCELLANEOUS ISSUES Do you currently have a will? Do you currently have a revocable trust? Do you currently have a durable power of attorney and a health care power of attorney? Are there any life insurance policies on your life that are owned by third parties (children, trusts, or companies)? Are you currently the beneficiary of any Trust arrangement? Have you established a trust of any type? Are you expecting any substantial inheritances? Have you ever lived in a Community Property State (California, Texas, New Mexico, Arizona, Washington, Louisiana, Nevada, or Idaho)? Have you ever made any substantial gifts (greater than $10,000 per year) or filed a gift tax return? Have you ever signed a prenuptial agreement, a post-nuptial agreement or an elective share waiver? Do you have any health problems that may be relevant to this estate plan? Do you have disability income insurance? If so, please describe the amount of insurance that you carry. Have you started a gift program for children or grandchildren? What is the name, address and phone number of your accountant? Do you own have joint accounts with anyone? Are any of your beneficiaries handicapped or disabled? Do you have long-term care insurance? Back
