JoAnn M. Perez, P. C.

 

ESTATE PLANNING FACT SHEET

 

Date: _______________      County of Residence:_______________          CM:________

 

 

 

 

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 child’s 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

 

                         Company Name and Policy Number                                          Face Amount

 

____________________________________________________________  $__________

____________________________________________________________  $__________

____________________________________________________________  $__________

____________________________________________________________  $__________

____________________________________________________________  $__________

 

 

RETIREMENT BENEFITS

 

                      Company Name and Type of Account                                              Amount

____________________________________________________________  $__________

____________________________________________________________  $__________

____________________________________________________________  $__________

____________________________________________________________  $__________

____________________________________________________________  $__________

 

ANNUAL INCOME

Wages                                      $__________

Rental/Investment                      $__________

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                                                                         VALUE                TOTAL VALUE

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 – LIABILITES =

TOTAL EQUITY                                                                                            $_________

 

 

ESTATE PLANNING OBJECTIVES

(Please indicate your concerns regarding your estate planning)

 

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________