Estate Planning Worksheet Individual Re: Estate Planning QuestionnaireEnclosed 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: tpEnclosuresESTATE PLANNING WORKSHEETPlease 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 CANIf there is not enough space to enter all the information, please feel free to add a separate sheetWE LOOK FORWARD TO SEEING YOU! ALL INFORMATION PROVIDED IS STRICTLY CONFIDENTIAL. PERSONAL INFORMATIONCLIENT’S NAME(Print name as you want it to appear in your documents)Birth Date YYYY slash MM slash DD SS#US Citizen? Yes NoHome Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home TelephoneCell Phone NumberEmail It is okay to communicate with me via E-mail.OccupationEmployerStatus Married Divorced Widowed SingleDate of Marriage YYYY slash MM slash DD CohabitingDomestic Partnership Registration Filed? Prenuptial Agreement? Postnuptial Agreement?If Divorced, does the order/judgment/settlement agreement restrict your devise of property?Children name(s)Date(s) of Birth of ChildrenDESIGNATION INFORMATIONPERSONS TO ACT FOR YOU – IF YOU ARE UNABLE TO ACT FOR YOURSELFDURABLE 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 NumberRelationship HEALTH CARE DECISION MAKERSIf 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 NumberRelationship Do you want to be cremated?Are you an organ donor?Do you want a living will? Yes NoGUARDIANSHIPIf 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 NumberRelationship 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 NumberRelationship 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/inheritanceName Address and Phone NumberRelationship Successors (if applicable)if the above named are unable or unwilling to act.Name Address and Phone NumberRelationship 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 spousethen to those named as follows:Note: If you are creating a trust, distributions will be discussed with the attorney at the meeting.DistributionNameParent/RelationshipBirth dateSpecific share in estate If stepchildren, are they to be treated as children of stepparent? Yes NoIf 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.)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.)NameRelationshipBirth dateSpecific share in estate IF APPLICABLE, CHILDREN OR OTHER HEIRS WHO WILL NOT RECEIVE SHARE IN ESTATE:(Use full legal name)NameRelationship ADVISORSNameTelephoneAccountantAccountantFinancial AdvisorFinancial AdvisorLife Insurance AgentLife Insurance AgentINCOME/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 PROPERTYPlease 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)ListAddressOwner(s) & How Titled * * (Tenants in common, Joint Tenants with Right of Survivorship, Tenancy by the Entireties)PERSONAL PROPERTYTYPE: 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 EffectsBANK & SAVINGS ACCOUNTSTYPE: 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 hereName of Institution &Type of AccountOwners (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 BONDSTYPE: 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 AccountsTypeOwners (if jointly owned) LIFE INSURANCE POLICES AND ANNUITIESTYPE: 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 PLANSTYPE: 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 INTERESTSTYPE: 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 DebtorDate Of NoteMaturity DateOwed ToCurrent Balance TotalANTICIPATED INHERITANCE, GIFT, OR LAWSUIT JUDGMENTTYPE: 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. DescriptionOTHER ASSETSTYPE: Other property is any property that you have that does not fit into any listed categoryTypeOwner(s) if jointly owned SUMMARY OF VALUES**IF YOU PREFER, YOU CAN WAIT UNTIL AFTER OUR MEETING TO SUPPLY AMOUNTS/VALUES** Amount*ASSETSTotal ValueReal PropertyReal PropertyFurniture and Personal EffectsFurniture and Personal EffectsBank and Savings AccountsBank and Savings AccountsStocks and BondsStocks and BondsLife Insurance and AnnuitiesLife Insurance and AnnuitiesRetirement PlansRetirement PlansBusiness InterestsBusiness InterestsMoney owed to youMoney owed to youAnticipated Inheritance, etc.Anticipated Inheritance, etcOther AssetsOther AssetsTotal Assets:Total Assets:ADDITIONAL INFORMATION FROM ANYTHING ABOVE OR ANYTHING ELSE YOU BELIEVE TO BE HELPFULΔ