Following is a data collection form we use to prepare estate planning documents.
ESTATE PLANNING WORKSHEET
PLEASE FILL OUT THE FOLLOWING INFORMATION TO THE BEST OF YOUR ABILITIES, PAYING SPECIAL ATTENTION TO SPELLING OF NAMES
I. Personal information
Husband Name:____________________________
Wife Name:________________________________
Address: ________________________________
________________________________
Husband Date of Birth:____________
Husband SS No.:_________________
Wife Date of Birth:_______________
Wife SS No.:_____________________
II. Beneficiaries
Do you want everything to go to the surviving spouse first?___________________________
Is this a first or subsequent marriage?________________________
Here, list other people you would like to receive a part of your estate, including family members, friends, and charities.
Children’s Names Address Date of Birth
1. __________________________ ___________________________ ______________
2. __________________________ ___________________________ ______________
3. __________________________ ___________________________ ______________
4. __________________________ ___________________________ ______________
Other Individuals: (Include friends, grandchildren, brothers and sisters, or anyone else to whom you would like to give a part of your estate.)
Name
_____________________
_____________________
_____________________ Address
________________________
________________________
________________________ Relationship
____________
____________
____________ Date of Birth
____________
____________
____________
Charities: (List any religious or other non-profit organizations to whom you would like to make a bequest. This may reduce the taxes on your estate.)
Charity
________________________________________
________________________________________Bequest
___________________________________
___________________________________
III. Executor and Successor Trustee
Name the person or persons you would like to appoint to administer your estate and/or Trust and their address and telephone number. He or she -- in which case she is called the "executrix" -- will carry out your wishes as stated in your will. Two people may serve together in this role. Also name an alternate in case the first appointed cannot serve for any reason.
Executor, executrix Address/Phone
1. _______________________________ ________________________________
2. _______________________________ ________________________________
IV. Attorney-In-Fact
Name the person you would like to appoint to handle your business affairs in the event of your incapacity, and their address and telephone number. He or she will act on your behalf should you be unable to handle your own affairs.
Attorney-In-Fact Address/Phone
1. _______________________________ ________________________________
Name the person you would like to appoint to make medical decisions on your behalf should you be unable to, and their address and telephone number. He or she will be responsible for making major medical decisions in accordance with your wishes as stated in your Advance Directive. Also name an alternate in case the first appointed cannot serve for any reason.
Health Care Representative Address/Phone
1. _______________________________ ________________________________
2. _______________________________ ________________________________
V. Lifetime Fiduciaries
Should you at any time in the future become incapacitated, it may be necessary for the Court to appoint a Guardian or Conservator to represent you. Name the person you would like to appoint to serve as Guardian or Conservator, and their address and telephone number. Also name an alternate in case the first appointed cannot serve for any reason.
Guardian Address/Phone
1. _______________________________ ________________________________
2. _______________________________ ________________________________
Conservator Address/Phone
1. _______________________________ ________________________________
2. _______________________________ ________________________________
VI. Guardian of Children
The most important purpose of a will for most younger people is the appointment of a guardian for their children under age 18. All people with children should have wills for this purpose. Again, two people may serve together in this role. Also name an alternate in case the first appointed cannot serve for any reason
Guardian’s Name(s) Address/Phone
1. _______________________________ ________________________________
2. _______________________________ ________________________________
You may wish for someone other than the Guardian to handle financial matters concerning your children. That person would be named the Trustee of any Testamentary Trust created for their benefit. Again, two people may serve together in this role. Also name an alternate in case the first appointed cannot serve for any reason
Trustee’s Name(s) Address/Phone
1. _______________________________ ________________________________
2. _______________________________ ________________________________
VII. Your Estate
List the contents of your estate, including bank accounts, stock, IRAs, real estate, motor vehicles, life insurance, and anything else that you may own, whether by yourself or with another person. For this purpose, an estimate of the value is sufficient.
Bank Accounts (financial institution and account numbers)
1. ______________________________________________ $______________
2. ______________________________________________ $______________
3. ______________________________________________ $______________
Real Estate
1. _____________________________________________ $______________
2. _____________________________________________ $______________
Stocks, Bonds, Treasury Notes, Other Investments
1. ______________________________________________ $______________
2. ______________________________________________ $______________
3. ______________________________________________ $______________
Life Insurance, IRAs, Pension, 401K
Death Benefit Cash Value
1. ____________________________ $_____________ $______________
2. ____________________________ $_____________ $______________
3. ____________________________ $_____________ $______________
Tangible Personal Property
(This category includes vehicles, furniture, jewelry or artwork -- anything of significant value or that you would like to go to a particular person.)
Item
____________________________
____________________________
____________________________
____________________________
____________________________ Value
______________
______________
______________
______________
______________ Gift to Whom
___________________________
___________________________
___________________________
___________________________
___________________________
VIII. Burial Instructions
Please state below any specific wishes you may have for your burial:
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________________________________________
____________________________________________________________________________________
FOR OFFICE USE ONLY
I. Durable POA ____
II. Health Care POA ______
III. Mental Health Care POA ______
IV. Nomination of Fiduciaries _______
V. Will ____
_____ Pourover _____ Simple, no residuary trust _____ With residuary trust
VI. Trust ____
_____ Revocable _____ Tax Planning, A/B Trust _____ Irrevocable
Schedule A to include:
_______ Real Property:___________________________________________________
_______ Personal Property:________________________________________________
_______ Other:_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
VII. Deed ____ _____ Bargain and Sale Deed _____ Bargain/Sale with Life Estate
Property Address: ____________________________________________________________
____________________________________________________________
Legal Description: Client provide deed? ________ Order Cust Svc Report? _________
Grantor(s): __________________________ Grantee(s): ______________________________