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ESTATE PLANNING QUESTIONNAIRE

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What name do you want for your trust?____________________________________ (Most Common: The Doe Family Trust) ________________________________________________________________________________________ Your full legal name Date of Birth Soc. Sec. # Status? (Circle) Married Single Widowed Divorced ________________________________________________________________________________________ Spouse full legal name Date of Birth Soc. Sec. # _________________________________________________________________________ Home Address City County State Zip PHONE ( )________________ Home United States Citizen? (Circle) Yes No Spouse? Yes No Nationality: _____________________________ Spouse: United States Citizen? (Circle) Yes No Nationality: _____________________________ Your Children Or Grand-Children Children Names and ages? Of both?, His?, Hers? Of Both? Adopted? Guardians info, if needed? _________________________________________________________ Full legal name Date of Birth Status? (Circle) Married Single Widowed Divorced _________________________________________________________________________ Home Address City County State Zip Children: Names and ages? Of both?, His?, Hers? Of Both? Adopted? Guardians info, if needed? _____________________________________________________________________________________ Full legal name Date of Birth Status? (Circle) Married Single Widowed Divorced _________________________________________________________________________ Home Address City County State Zip Children: Names and ages? Of both?, His?, Hers? Of Both? Adopted? Guardians info, if needed? _____________________________________________________________ Full legal name Date of Birth Status? (Circle) Married Single Widowed Divorced _________________________________________________________________________ Home Address City County State Zip Deceased children? Yes No (If So State Below) Did they have children? Yes No (If So State Below) _______________________________________________________________________________________ _______________________________________________________________________________________. Wish to disinherit any children or grandchildren? (List in notes below) ________________________________________________________________________________________ ________________________________________________________________________________________ Grandchildren? (Number) ____ Any Grandchildren Minors? Yes No (May need Grandchildren's Trust) Any above receiving Government benefits for being blind, disabled or retarded, etc.? (Circle) Yes No (May need a Special Needs Trust To Avoid The Loss Of Benefits Or The Government Getting Funds!) Notes:________________________________________________________________________________ ________________________________________________________________________________________ Existing Structures Please indicated How Title Is Held: Please Abbreviate: Joint Tenant = JT, Community Property = CM, Husbands Sole & Separate = HSS, Wife's Sole & Separate = WSS. List Any Estate Planning You Have, Including The Types Of Instruments And Under What State Law: ________________________________________________________________________________________ ________________________________________________________________________________________ When Was Your Will Executed And Under What State Laws Was It Drafted? _________________________________. When Was Your Spouse's Will Executed And Under What State Law Was It Drafted? __________________________. Do You Participate In Any Of The Following? __ Pension Plan __Profit -Share Plan __Deferred Compensation Plan __401(K) Plan __ Other __________________ Have You Or Your Spouse Used Or Do You Currently Us A Name Other Than That Provided For Above? Give Full Details: _______________________________________________________________________________.   Who Will Inherit Your Estate Upon Your Death?   BENEFICIARIES Normally you during your lifetime(s) no need to indicate yourselves if assets going to surviving spouse. If not, state the complete details: _________________________________________ ________________________________________________________________________________________. Contingent Beneficiaries - Equally to children listed [ ] Exclusions [ ]. Other [ ] ________________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Second contingent beneficiaries- Children of deceased child [ ] In Trust to age 25 [ ] Other age ____ (I recommend that a sub-trust be set up as follows: 1/3 at age 20; 1/3 age 25 and Balance Age 30) __________________________________________________________________________ __________________________________________________________________________ Named Beneficiaries? ____________________ Other? ___________________ __________________________________________________________________________ __________________________________________________________________________ Special gifts to charity or individuals can be achieved using the Trust Amendment for Gifting provided [ ] TRUSTEE/MANAGERS (Normally You during your lifetime(s)) NO NEED TO LIST SELVES If child of the deceased spouse to act as a co-trustee to protect interest (indicate) [ ] None [ ] Oldest then-living child of deceased spouse [ ] Other _______________ ________________________________________________________________________________________ Subsequent Trustee(s)? (To manage on your death or disability) Address & Telephone Number ________________________________________________________________________________________ Second Subsequent Trustee(s)? (If Subsequent Trustee cannot or will not manage) Address & Telephone Number   ________________________________________________________________________________________ Third Subsequent Trustee(s)? (If Second Subsequent Trustee cannot or will not manage) Address & Telephone Number Will professional Corporate Trustee be needed? (Circle) Yes No Will Trustees above act as Executors on Wills and/or Agents on Durable Powers of Attorney? __Yes __ No If Not, state the name and address of the Executor (Only If Your Spouse Does Not Survive You) _______________________________________________________________________________________. Name And Address & Telephone Number _______________________________________________________________________________________ Subsequent Executor Address & Telephone Number ________________________________________________________________________________________ Subsequent Executor Address & Telephone Number ________________________________________________________________________________________ Subsequent Executor Address & Telephone Number Will Trustees above act as the Guardian Of Your Minor Children? ____ Yes ___ No If Not, state the name and address of the Guardian (Only If Your Spouse Does Not Survive You) _______________________________________________________________________________________. Name Of Guardian And Address & Telephone Number _______________________________________________________________________________________ Subsequent Guardian Address & Telephone Number ________________________________________________________________________________________ Subsequent Guardian Address & Telephone Number ________________________________________________________________________________________ Subsequent Guardian Address & Telephone Number   ASSETS: Own home? Yes No Value? $________,000 Savings? - CDs? - Stock? - Bonds? - Funds? - IRAs, Pensions, 401 k, Etc.? - Other? (Circle) Do you currently have Life Insurance Face Amount $______________ Spouse $___________________ If so make sure you include this in your total estate value! (You may want to create a Life Insurance Trust To Legally avoid the Estate Tax to your Estate!) Gross value of estate $_____. Net value $________ (If more property and accounts you can add pages.) Are you planning on selling any real or personal property (including Stocks, bonds etc.) where you may have capital gains? If so, please give the details: ______________________________________________________________. ******[Note: You may not be aware that you can avoid all of the capital gains by using for example, A Charitable Remainder Trust (Private or Public Charities May Apply) so please contact a professional for complete advise prior to any transaction!]   OTHER INFORMATION NEEDED TO COMPLETE PLAN? Yes No (Add pages & #) We want information on protecting savings from nursing home risk? [] Additional Planning? [] Give Details:__________________________________________________________________________ Item 1. REAL PROPERTY LOCATED AT_________________________________________ 2. FURNITURE 3. HOUSEHOLD EFFECTS 4. PERSONAL EFFECTS 5. JEWELRY 6. BANK, SAVINGS & INVESTMENTS, WHEREVER LOCATED. 7. AUTOMOBILES 8. LIFE INSURANCE POLICIES WHEREVER LOCATED. 9. TRUSTORS ' RETIREMENT BENEFITS 10. TRUSTORS' CLAIMS REGARDING HER/HIS PERSON, PROPERTY, OF EVERY NATURE THAT HE WOULD BE ENTITLED TO RECEIVE OR ENFORCE, OR FOR WHICH HER/HIS ESTATE WOULD BE ENTITLED TO RECEIVE OR ENFORCE, WHETHER BY SUIT, ADMINISTRATIVE PROCEEDING, SETTLEMENT ETC. ADDITIONAL ASSETS OR INSTRUCTIONS Business Interests! If any & type (Corp. Partnership. Etc.) ________________________________________________________________________________________ ________________________________________________________________________________________ INFORMATION FOR MEDICAL POWER OF ATTORNEY Each Spouse Please fill out. Will Trustees above act as the Designated Agent? ____ Yes ___ No (If not list below) Designated Agent & Conservator of Person & Alternatives 1.______________________________________________________________________________________ Name Address Telephone 2.______________________________________________________________________________________ Name Address Telephone 3.______________________________________________________________________________________ Name Address Telephone Statement of Desires Concerning Life­Sustaining Treatment and Special Provisions. *[First alternative: prolong life]_________I express the desire that my life be prolonged to the greatest possible extent without regard for my physical or mental condition, chance of recovery, likelihood of suffering, or expense and authorize my agent to consent to whatever medical procedures are necessary to accomplish this end. I trust my agent, who knows my desires well, and in whose judgment I have absolute faith to exercise my agent's discretion in a manner that would be satisfactory to me. *[Second alternative: withhold/withdraw life­sustaining treatment] _______4.1 If I should have an incurable injury, disease, or illness certified by two (2) physicians to be a terminal condition, and if the application of life­sustaining procedures would serve only to artificially prolong the moment of my death, and if my treating physician determines that my death is imminent, whether or not life­sustaining procedures are utilized, then I desire that all life­sustaining treatment be withheld or removed. *[Optional] _______If I am in a coma and have been for at least ___ (STATE NUMBER) days, which two (2) of physicians have diagnosed as irreversible (i.e., if there is no reasonable possibility that I will regain consciousness), then I desire that all life­sustaining treatment be removed or withheld. *[Third alternative: Withhold/withdraw life­sustaining treatment ­ burdens of treatment outweigh benefits] _________ 4.1 If in my agent's judgment the burdens of the proposed treatment outweigh the expected benefits, then I desire that all life­sustaining treatment be withheld or withdrawn. I desire that my agent consider relief from suffering, preservation or restoration of functioning, and the quality as well as the extent of the life being preserved when decisions are made concerning life­sustaining care, treatment, services, and procedures. *[Fourth alternative: withhold/withdraw life­sustaining treatment ­ restoration of cognitive state] _______4.1 If the extension of my life would result in a mere biological existence, devoid of cognitive function, with no reasonable hope for normal functioning, then I do not desire any form of life­sustaining procedures, *[including nutrition and hydration unless necessary for my comfort or alleviation of pain,] or, if life­sustaining treatment has been instituted, I desire that it be withdrawn. It is my desire that my agent consider relief from suffering, preservation, or restoration of functioning, and the quality as well as extent of the life being preserved when decisions are made concerning life­sustaining care, treatment, services, and procedures. In making the decision to withhold or remove treatment, my agent should ask the question: "Is the proposed treatment an aid to recovery or merely a prolongation of inevitable death?" What is "reasonable," what is "an aid to recovery," and what is "merely a prolongation of inevitable death" shall be determined by my agent after consulting with my attending physicians. *[Optional] [Do not use if the fourth alternative, above, is chosen] __________Regardless of my condition, it is my desire to receive nutrition and hydration in all ways possible. *[Optional] _______But if I remain in a coma for ___ (STATE NUMBER) days, my agent is instructed not to continue nutrition and hydration by any artificial means so long as they are not necessary for comfort or alleviation of pain. OTHER WISHES: (If you do not agree with any of the optional Choices above and wish to write your own, or if you wish to add to the instructions you have given above, you may do so here.) I direct that: _____________________________________________________________ Autopsy, Anatomical Gifts, Disposition of Remains. Upon my death (mark applicable selections): ___ (a) I give any needed organs, tissues, or parts, Or ___ (b) I give the following organs, tissues, or parts only: __________________ _________________________________________________________________________. My gift is for the following purposes [check applicable restrictions]: ___(1) Transplant ___(2) Therapy ___(3) Research ___(4) Education I want my remains disposed of as follows: _____________________________________________________________________________ (Buried or Cremated With Instructions) ______________________________________________________________________________. Part IV PRIMARY PHYSICIAN (OPTIONAL) I designate the following physician as my primary physician: _______________________________________________________________________________ Name Address Telephone OPTIONAL: If the physician I have designated above is not willing, able, or reasonably available to act as my primary physician, I designate the following physician as my primary physician: _______________________________________________________________________________ Name Address Telephone REMEMBER, IT'S NOT WHAT YOU EARN IT'S WHAT YOU KEEP!

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