ESTATE PLANNING FACT SHEET

MARRIED COUPLE

 

Date: _______________      County of Residence:_______________          CM:________

 

 

 

 

Husbandís Name: _________________________________________________________

Primary Occupation: ______________________________________________________

Birthdate:________________________           Social Security #:____________________

 

 

Wifeís Name: ____________________________________________________________

Primary Occupation: ______________________________________________________

Birthdate:________________________           Social Security #:____________________

Address: ________________________________________________________________

Electronic Mail Addresses: _________________________________________________

Telephone: Home:_________________                   Business:______________________

U.S. Citizen: Yes__ No__     Safe Deposit Box: No__ Yes__

 

CHILDREN

(If any child is adopted, please place an asterisk beside that childís name and furnish additional information on back)

 

                                                            Name                                                 Birthdate

Oldest Child                 ______________________________            __________________

Second Child                ______________________________            __________________

Third Child                   ______________________________            __________________

Fourth Child                 ______________________________            __________________

Fifth Child                    ______________________________            __________________

 

OTHER DEPENDENTS

 

Name                                                 Birthdate

First Dependent            ______________________________            __________________

Second Dependent       ______________________________            __________________

 

PROFESSIONAL ADVISERS

 

                               Accountant                    Financial Adviser     Insurance Agent

 

Name               __________________      __________________      _________________

Firm                 __________________      __________________      _________________

Address           __________________      __________________      _________________

Telephone        __________________      __________________      _________________

 

 

HEALTH CARE PROXY NOMINATIONS

(Select in order of preference who you wish to serve as your Health Care Proxy to make

medical decisions for you when you are unable to communicate your wishes.)

 

HealthCare

Proxy                 1)_________________   2)__________________  3)________________

 

WILL NOMINATIONS

(Select in order of preference who you wish to serve in the following capacities.

Select Guardians only if you have minor children.)

Personal

Representative    1)_________________   2)__________________  3)________________

Trustee               1)_________________   2)__________________  3)________________

Guardian            1)_________________   2)__________________  3)________________

 

 

POWER OF ATTORNEY NOMINATIONS

(Select in order of preference who you wish to serve as your Attorney in Fact.)

 

Agent               1)_________________   2)__________________  3)________________

 

 

INSURANCE POLICIES

 

        Insuredís Name           Company Name and Policy Number            Face Amount

 

_______________________    ___________________________________  $__________

_______________________    ___________________________________  $__________

_______________________    ___________________________________  $__________

_______________________    ___________________________________  $__________

_______________________    ___________________________________  $__________

_______________________    ___________________________________  $__________

_______________________    ___________________________________  $__________

 

 

RETIREMENT BENEFITS

 

         Account Owner                    Company Name and Type of Account             Amount

_______________________    ___________________________________  $__________

_______________________    ___________________________________  $__________

_______________________    ___________________________________  $__________

_______________________    ___________________________________  $__________

_______________________    ___________________________________  $__________

 

ANNUAL INCOME

Husband                       $__________

Wife                             $__________

TOTAL                        $__________

 

OTHER INCOME/INHERITANCES

(Please indicate any income source not previously listed and any potential inheritances)

 

Source of Income                                                                                                  Amount

_______________________________________                                          $__________

_______________________________________                                          $__________

_______________________________________                                          $__________

_______________________________________                                          $__________

 

ASSET/LIABILITY SUMMARY

(List total for each category.  If more than one piece of property or account,

list each individual item on back.)

 

ASSETS                                      JOINT                     HUSBAND                     WIFE

Home - Value                           $__________              $__________              $_________

Personal Effects                        $__________              $__________              $_________

Other Real Estate                      $__________              $__________              $_________

Bank Accounts                         $__________              $__________              $_________

Certificates of Deposit               $__________              $__________              $_________

Marketable Securities                $__________              $__________              $_________

Non-Marketable Securities       $__________              $__________              $_________

Retirement Accounts                 $__________              $__________              $_________

Business Interests                      $__________              $__________              $_________

Cash                                         $__________              $__________              $_________

Other Assets                            $__________              $__________              $_________

TOTAL ASSETS                     $__________              $__________              $_________

 

LIABILITIES

Mortgages Payable                   $__________              $__________              $_________

Credit Card Debt                     $__________              $__________              $_________

Vehicle Loans                           $__________              $__________              $_________

Bank Loans                              $__________              $__________              $_________

IRS Debt                                  $__________              $__________              $_________

Other Debts                             $__________              $__________              $_________

           

TOTAL LIABILITIES            $__________              $__________              $_________

 

ASSETS Ė LIABILITES =

TOTAL EQUITY                    $__________              $__________              $_________

 

 

ESTATE PLANNING OBJECTIVES

(Please indicate your concerns regarding your estate planning)

 

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