Estate Planning Worksheet Individual

Re: Estate Planning Questionnaire

Enclosed is an Estate Planning Questionnaire for your completion. Please do not worry about total accuracy – just do the best you can.

Although you should not spend an inordinate amount of time gathering the information, we have found that having this data available at the initial conference greatly aids both us and the client in focusing on estate planning issues.

Of importance is the family information, including the specific ownership of each asset. Although this covers a lot of information, it is necessary to the planning process and, perhaps more importantly, its completion at the outset enables us to keep costs down for you.

The financial amounts/values are not necessary before you come in, but we will discuss those in the consultations.

Once you complete the form, it will automatically be send it to us at iva@difranzalaw.com.

Sincerely yours,

DIFRANZA LAW, P.A.

Lisa A. DiFranza

LAD: tp

Enclosures

ESTATE PLANNING WORKSHEET

Please return the completed worksheet to us at least three days prior to our meeting (this will ensure we have enough time to understand the specifics of your situation before our meeting). If you need assistance completing the information, call our office (904-372-0216) and we will be glad to help you.

PLEASE DON’T WORRY ABOUT TOTAL ACCURACY

– JUST DO THE BEST YOU CAN

If there is not enough space to enter all the information, please feel free to add a separate sheet

WE LOOK FORWARD TO SEEING YOU!

ALL INFORMATION PROVIDED IS STRICTLY CONFIDENTIAL.

PERSONAL INFORMATION

CLIENT’S NAME

(Print name as you want it to appear in your documents)

Birth Date

SS#

US Citizen?

Yes
No

Home Address

Street Address City State / Province / Region ZIP / Postal Code Country

Home Telephone

Cell Phone Number

Email

It is okay to communicate with me via E-mail.

Occupation

Employer

Status

Married
Divorced
Widowed
Single

Date of Marriage

Cohabiting

Domestic Partnership Registration Filed?

Prenuptial Agreement?

Postnuptial Agreement?

If Divorced, does the order/judgment/settlement agreement restrict your devise of property?

DESIGNATION INFORMATION

PERSONS TO ACT FOR YOU – IF YOU ARE UNABLE TO ACT FOR YOURSELF

DURABLE POWER OF ATTORNEY (decisions re: property, finances while you are living):

Who do you want making decisions regarding the management of your property?

Name Address and Phone Number	Relationship

HEALTH CARE DECISION MAKERS

If you were unable to make decisions for yourself, who would you want to make decisions for you with regard to your medical treatment?

Name Address and Phone Number	Relationship

Do you want to be cremated?

Are you an organ donor?

Do you want a living will?

Yes
No

GUARDIANSHIP

If a guardianship is needed, who do you want making decisions regarding the management of your personal and property?

(Although the above documents will hopefully eliminate the need for a court supervised guardianship, certain circumstances may require the appointment of a legal guardian. This document will indicate your preference for the court appointment.)

Name Address and Phone Number	Relationship

PERSONAL REPRESENTATIVE (PR) (management of estate according to your last will & testament):

Who do you want making decisions regarding the management and distribution of your assets to your beneficiaries after you pass? (this is also known as an Executor/Executrix)

Name Address and Phone Number	Relationship

GUARDIAN FOR MINOR CHILDREN (IF APPLICABLE):

If you have any children under the age of 18, list in order of preference who would raise them and love them in the manner as close as possible to the way you would. You can name an individual/couple to care for the person and another individual/couple to manage the property/inheritance

Name Address and Phone Number	Relationship

Successors (if applicable)

if the above named are unable or unwilling to act.

Name Address and Phone Number	Relationship

GUARDIAN FOR PETS (instructions):

DISTRIBUTIONS UPON DEATH:

Mutual survivorship

Yes
No

(each spouse survives the other if simultaneous)

Distribution will be:

To the following
All to spouse

then to those named as follows:

Note: If you are creating a trust, distributions will be discussed with the attorney at the meeting.

Distribution

Name	Parent/Relationship	Birth date	Specific share in estate

If stepchildren, are they to be treated as children of stepparent?

Yes
No

If a named individual or charity named above does/do not survive you or exist, who do you want to receive their share? (children of children, other charity, share to be returned to residue to be distributed to surviving beneficiaries, etc.)

Name	Relationship	Birth date	Specific share in estate

IF APPLICABLE, CHILDREN OR OTHER HEIRS WHO WILL NOT RECEIVE SHARE IN ESTATE:

(Use full legal name..)

Name	Relationship

ADVISORS

Name

Telephone

Accountant

Accountant

Financial Advisor

Financial Advisor

Life Insurance Agent

Life Insurance Agent

INCOME/ASSET/LIABILITY INFORMATION

**IF YOU PREFER, YOU CAN WAIT UNTIL AFTER OUR MEETING TO SUPPLY AMOUNTS/VALUES**
Please list your income/asset/liability information in the appropriate section below.
Attach additional pages, if necessary.

REAL PROPERTY

Please list any interest in real estate including your family residence, vacation home, time share or vacant land.
(please list manner in which title held – Joint Tenant, Community Property, Separate Property, Tenant in Common)

List

Address	Owner(s) & How Titled *

* (Tenants in common, Joint Tenants with Right of Survivorship, Tenancy by the Entireties)

PERSONAL PROPERTY

TYPE: List separately only major personal effects such as, jewelry, collections, antiques, furs, and all other valuable non-business personal property (indicate type below and give a lump sum value for miscellaneous, less valuable items.).

Type or Description

Miscellaneous Furniture and Household Effects

BANK & SAVINGS ACCOUNTS

TYPE: Checking Account “CA”, Savings Account “SA”, Certificates of Deposit “CD”, Money Market “MM” (indicate type below).
Do not include IRA’s or 401(k)’s here

Name of Institution &Type of Account	Owners (if jointly owned)

Note: If Account is in your name (or your spouse’s name) for the benefit of a minor, please specify and give minor’s name.

STOCKS AND BONDS

TYPE: List any and all stocks and bonds you own. If held in a brokerage account, lump them together under each account. (indicate type below)

Stocks Bonds or Investment Accounts	Type	Owners (if jointly owned)

LIFE INSURANCE POLICES AND ANNUITIES

TYPE: Term, whole life, split dollar, group life, annuity. ADDITIONAL INFORMATION: Insurance company, type (whole, term, etc.), face amount (death benefit), whose life is insured, who owns the policy, the current beneficiaries, who pays the premium, and who is the life insurance agent.

RETIREMENT PLANS

TYPE: Pension (P), Profit Sharing (PS), H.R. 10, IRA, SEP, 401(K). ADDITIONAL INFORMATION: Describe the type of plan, the plan name, the current value of the plan, and any other pertinent information.

BUSINESS INTERESTS

TYPE: General and Limited Partnerships, Sole Proprietorships, privately owned corporations, professional corporations, oil interests, farm and ranch interests. ADDITIONAL INFORMATION: Give a description of the interests, who has the interest, your ownership in the interests, and the estimated value of the interests.

MONEY OWED TO YOU

**IF YOU PREFER, YOU CAN WAIT UNTIL AFTER OUR MEETING TO SUPPLY AMOUNTS/VALUES**

TYPE: Mortgages or promissory notes payable to you, or other moneys owed to you.

Name of Debtor	Date Of Note	Maturity Date	Owed To	Current Balance

Total

ANTICIPATED INHERITANCE, GIFT, OR LAWSUIT JUDGMENT

TYPE: Gifts or inheritances that you expect to receive at some time in the future; or moneys that you anticipate receiving through a judgment in a lawsuit. Describe in appropriate detail.
Description

OTHER ASSETS

TYPE: Other property is any property that you have that does not fit into any listed category

Type	Owner(s) if jointly owned

SUMMARY OF VALUES

IF YOU PREFER, YOU CAN WAIT UNTIL AFTER OUR MEETING TO SUPPLY AMOUNTS/VALUES

Amount*

ASSETS

Total Value

Real Property

Real Property

Furniture and Personal Effects

Furniture and Personal Effects

Bank and Savings Accounts

Bank and Savings Accounts

Stocks and Bonds

Stocks and Bonds

Life Insurance and Annuities

Life Insurance and Annuities

Retirement Plans

Retirement Plans

Business Interests

Business Interests

Money owed to you

Money owed to you

Anticipated Inheritance, Etc.

Anticipated Inheritance Etc

Other Assets

Other Assets

Total Assets:

Total Assets:

ADDITIONAL INFORMATION FROM ANYTHING ABOVE OR ANYTHING ELSE YOU BELIEVE TO BE HELPFUL