†††††††††††††††††††† CONFIDENTIAL ESTATE PLANNING INFORMATION FORM

††††††††††††††††††††††††††††††††††††††††††††††††††† (SINGLE INDIVIDUALS)

 

This questionnaire was developed for use by ALAN S. GASSMAN, P.A. in designing comprehensive estate plans for clients.The information which you supply on this form will be retained in our files and no information will be released to any person without your prior permission.

 

DATE:_____________________

 

1.†††††††† Full Name _______________________________________________†††††††††††††††††††††††††††††††††††† Date of Birth ________

Social Security No. ________________________________________†††††††††††††††††††††††††††††††††††† Place of Birth _______

Other Names Known By ____________________________________††††††††††††††††††††††††††††††††††† Citizenship __________

________________________________________________________

Occupation (former if retired) ________________________________

Employer ________________________________________________

Office Telephone No. ______________________________________

Fax No. (do we need to call you before faxing?)__________________

Any serious health problems?†††††† __ Yes __ No

2.†††††††† Residence

Home Address ____________________________________________

________________________________________________________

Home Telephone No._______________________________________

Fax No. (do we need to call you before faxing?)__________________

Other Residences__________________________________________

________________________________________________________

Resident Since _____________________________________

 

3.†††††††† Billing Address (if different)

________________________________________________________

________________________________________________________

4.†††††††† Advisors

Accountant_______________________________________________††††††††† Phone Number_____________

Trust Officer______________________________________________†††††††† Phone Number_____________

Insurance Agent___________________________________________††††††††† Phone Number_____________

Investment Advisor________________________________________ †††††††† Phone Number_____________

Pension Plan Advisor_______________________________________††††††††† Phone Number______________

May we speak to your advisors directly?†† ___†††††† Yes†††††† ___†††††† No

 


5.†††††††† Please circle any of the following states in which you have lived or acquired property:

Arizona†††††††††††† Idaho††††††††††††††† Nevada††††††††††††† Texas

California†††††††††††††††††††††† Louisiana†††††††††† New Mexico††††††††††††††††† Washington

Canada†† †††††††††††††††††††††† None of the above

 

6.†††††††† Names of Children (if adopted, indicate (A) after name; if deceased, please indicate (D) after name):

A.†††††††† Name________________________________________________††††††††††††††††††††††††††††† Date of Birth_________

Social Security Number__________________________________

Name of Childís Spouse (if any)___________________________

Address______________________________________________

Grandchildren_________________________________________

B.†††††††† Name________________________________________________††††††††††††††††††††††††††††† Date of Birth_________

Social Security Number__________________________________

Name of Childís Spouse (if any)___________________________

Address______________________________________________

Grandchildren_________________________________________

C.†††††††† Name________________________________________________††††††††††††††††††††††††††††† Date of Birth_________

Social Security Number__________________________________

Name of Childís Spouse (if any)___________________________

Address______________________________________________

Grandchildren_________________________________________

D.†††††††† Name________________________________________________††††††††††††††††††††††††††††† Date of Birth_________

Social Security Number__________________________________

Name of Childís Spouse (if any)___________________________

Address______________________________________________

Grandchildren_________________________________________

E.†††††††† Name________________________________________________††††††††††††††††††††††††††††† Date of Birth_________

Social Security Number__________________________________

Name of Childís Spouse (if any)___________________________

Address______________________________________________

Grandchildren_________________________________________

7.†††††††† Are there any family members who require special schooling, special medical attention, or other special attention?††††††† ____†††† Yes†††††† ____†††† No

If Yes, please give name(s) and describe nature of needs _________________________

______________________________________________________________________

 


8.†††††††† Do you have any other relatives now or likely in the future to be dependent upon you for support?

___ Yes___ No

If Yes, give name(s) and relationships ________________________________________

_______________________________________________________________________

9.†††††††† Do you have any legal obligations to a former spouse or children?†† ___Yes___††† No†††††††

If Yes, please provide copy of relevant document(s).

10.††††††† Do you have a present Will?___ Yes___ No

If Yes, please attach a copy.

11.††††††† Do you have any present Trusts?___ Yes___ No

If Yes, please attach a copy.

12.††††††† Have you ever received a substantial amount by inheritance?

__ Yes __ No†††† If Yes, when? ____________ Approximate amount $__________

Do you anticipate receiving an inheritance?___ Yes___ No

If Yes, give approximate amount $______________

13.††††††† Do you hold a power of appointment under another personís Will or Trust?††††††††††††

___Yes ___ NoIf yes, please attach a copy.

14.††††††† Have you given away more than $10,000 in money or property to any person in any single year after 1976?___ Yes___ No

Have you ever been required to file a gift tax return?

___ Yes†† ___ No If Yes, what years? _____________________________

Please attach copies of any gift tax returns.

15.††††††† Do you work for a business which has some type of plan under which your estate or the person you specify will receive benefits on your death?

___ Yes___ No___ Not Sure

16.††††††† Are you a party to a Shareholder or Partnership Agreement (including any Buy-Sell Agreements)?

___ Yes___ No

If Yes, please attach a copy.

17.††††††† Do you have a safe deposit box?___ Yes___ No

If Yes, where located? ______________________________________________

Name(s) box is listed under __________________________________________

18.††††††† Do you own any property in a foreign country? ___ Yes___ No

If Yes, give country and approximate value $____________________________

 

 

 

 


19.††††††† Please list any specific items or amounts that you wish to give to any individuals or organizations:

Name and Relationship†††

of Beneficiary††††††††††††††††††††††††††††††††††††††† Description of Gift

___________________________ __________________________________________________

___________________________ __________________________________________________

___________________________ __________________________________________________

___________________________ __________________________________________________

 

20.††††††† All other tangible personal property (automobiles, clothing, furniture, pictures, etc.) to be distributed to (check one):

___ Children equally

___ Other (specify) __________________________________________________________

__________________________________________________________________________

21.††††††† All remaining money and other property (stocks, bonds, mutual funds, etc.) to be distributed to:

___ Children equally

___ Other (specify) __________________________________________________________

__________________________________________________________________________

22.††††††† If you have named a beneficiary in Questions 20-22 above for whom full personal information has not already been provided (for example, a parent, aunt/uncle, niece/nephew, or friend), please provide that information here:

A.†††††††† Name____________________________________________†††††††††††††††††††††††††††††††††††† Date of Birth_________

Address__________________________________________

Relationship_______________________________________

B.†††††††† Name____________________________________________†††††††††††††††††††††††††††††††††††† Date of Birth_________

Address__________________________________________

Relationship_______________________________________

C.†††††††† Name____________________________________________†††††††††††††††††††††††††††††††††††† Date of Birth_________

Address__________________________________________

Relationship_______________________________________

23.††††††† Age(s) at which beneficiaries are to become in control of property held in trust for them or are to receive property outright--see attached Memorandum entitled Trust Systems for Children and Subsequent Generations.

(A)†††††† Traditional approach - distribute selected percentages at selected ages to the extent not otherwise spent.

(B)††††††† Protective approach - child becomes Co-Trustee at what age, selects Co-Trustee at what further age, and becomes sole Trustee at what eventual age?______________________________________________

________________________________________________________________________________________.


24.††††††† Please indicate below your choice as Executor (Personal Representative) of your estate and Successor Trustee of your Living Trust (if applicable).You will be the initial Trustee of your Living Trust.The Successor Trustee will act if you cannot due to resignation, incapacity or death. You may select an individual or a financial institution with trust powers under state law to act as Executor and Successor Trustee.You may also select more than one person or institution to act as Co- Executors or Co-Trustees at the same time, and you may provide that they may act with or without the joinder and consent of the other. Most clients select the same persons to act as both Executor and Successor Trustee, but thatís strictly a matter of personal choice.

 

Who will serve as Executor of your estate and Successor Trustee of your Living Trust?

Name:†††††††††††††††††††††††††† ___________________†††††††††††††† _____________________

Relationship:††††††††††††††††† ___________________†††††††††††††† _____________________

 

Please name alternates to serve if your first choice cannot:

First Alternate

Name:†††††††††††††††††††††††††† ___________________†††††††††††††† _____________________

Relationship:††††††††††††††††† ___________________†††††††††††††† _____________________

Second Alternate

Name:†††††††††††††††††††††††††† ___________________†††††††††††††† _____________________

Relationship:††††††††††††††††† ___________________†††††††††††††† _____________________

25.††††††† Your choice to act as Guardian of your minor children (if applicable):

First choice

Name(s) _________________________________ Relationship: _______________________

Address ____________________________________________________________________

Second choice

Name(s) _________________________________ Relationship: _______________________

Address ____________________________________________________________________

26.††††††† Are you presently involved in any litigation, or is there litigation or potential claims against you that are known? ____ Yes ____ No

27.††††††† Are you engaged in any high-risk ventures, professions, or circumstances that would make creditor planning important? _____ Yes _____ No

 

We will do your planning based upon the information described in this form.If you wish for us to verify any of this information, please let us know.We will be pleased to review any Deeds, Mortgages, account statements, or other confirmatory documentation, if requested.The specific ownership and designation of assets, liabilities and beneficiary designations must be coordinated properly for estate planning documents to function as intended.

The undersigned has reviewed this form and the following asset summary information and believe it to be accurate.

___________________________________________

Client


 

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† LIST OF ASSETS

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† (Attach additional sheets if necessary)

†††† †††††† Approximate Net Values

†††

1.†† Real Estate(please give approximate††† †††††††† †††††††† ††††††††

†††† value and approximate mortgage balance)†††††††† †††††††† ††††††††

†††† Home - Value $______________†††††††††† †††††††† †††††††† ††††††††

†††† Approximate mortgage balance†††††††††† †††††††† †††††††† ††††††††

†††† $_____________†††††††††††††††††††††††† †††††††† †††††††† ††††††††

†††† Other Real Estate (give location or††† †††††††† †††††††† ††††††††

†††† briefly describe:)________________†††† †††††††† †††††††† ††††††††

†††† __________________________________†††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† ††††† ††††††††††† †††† __________________________________†††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

†††† __________________________________†††† †††††††† †††††††† ††††††††

††††††††††††††† †††††††††††††††††††††††††††††††††††† †††††††† ††††††††

†††† __________________________________†††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

2.†† Stocks, Bonds, Mutual Funds††††††††††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

†††† A.†† Publicly traded stock--Name of††† †††††††† †††††††† ††††††††

††††††††† corporation.††††††††††††††††††††† †††††††† †††††††† †††††† ††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

††††††††† ______________________________††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

††††††††† ______________________________††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

††††††††† ______________________________††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††† †††††††††† ††††††††

†††† B.†† Closely held stock--Name of†††††† †††††††† †††††††† ††††††††

††††††††† corporation, number of shares†††† †††††††† †††††††† ††††††††

††††††††† and shareholders.†††††††††††††††† †††††††† †††††††† ††††††††

††† †††††††††††††††††††††††††††††††††††††††††††††††† †††††††† ††††††††

††††††††† ______________________________††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

††††††††† ______________________________††† †††††††† †††††††† ††††††††

 


†††† †††† Approximate Net Values

†††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

†††† C.†† Bonds and mutual funds--Issuer,†† †††††††† ††††††††††††††††

††††††††† face value, interest rate, and††† †††††††† †††††††† ††††††††

††††††††† maturity date; name of fund,††††† †††††††† †††††††† ††††††††

††††††††† fund group, and number of units.†††††††† †††††††† ††††††††

††††††† †††††††††††††††††††††††††††††††††††††††††††† †††††††† ††††††††

††††††††† _______________________________†† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

††††††††† _______________________________†† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

3.†† Bank accounts, certificates of†††††††† †††††††† †††††††† ††††††††

†††† deposit, money market funds, etc.††††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

†††† Please give name of bank or institu-†† †††††††† †††††††† ††††††††

†††† tion, type of account and approximate†††††††† †††††††† ††††††††

†††† balance or value.††††††††††††††††††††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

†††† __________________________________†††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

†††† __________________________________†††† †††††††† †††††††† ††††††††

†††††††††††††††††††††††††††††††† ††††††††††††††††††† †††††††† ††††††††

†††† __________________________________†††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

4.†† IRAís and Pension Plan Assets†††††††† ††† †††††††† †††††††† †††††††

__________________________________†††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

__________________________________†††† †††††††† †††††††† ††††††††

†††††††††††††††††††††††††††† ††††††††††††††††††††††† †††††††† ††††††††

__________________________________†††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

5.†† Mortgages, notes, or debts (owed to††† †††††††† †††††† ††††††††††

†††† you by someone else).††††††††††††††††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

†††† Please list debtor's name, date††††††† †††††††† †††††††† ††††††††

†††† acquired, and approximate balance††††† †††††††† †††††††† ††††††††

†††† remaining.†††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

†††† ___________________________________††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††† †††††††††† †††††††† ††††††††

†††† ___________________________________††† †††††††† †††††††† ††††††††


†††† †††† Approximate Net Values

†††

6.†† Other Business Interests (noncorporate)†††††††† †††††††† ††† †††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

†††† ___________________________________††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

†††† ___________________________________††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

7.†† Partnership or other investments not†† †††††††† †††††††† ††††††††

†††† listed above.††††††††††††††††††††††††† ††† ††††††††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

8.†† Miscellaneous Property†††††††††††††††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

††† Motor vehicles (including boats, etc.; †††††††† †††††††† ††††††††

†††† List total value)††††††††††††††††††††† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

†††† Jewelry†††††††††††††††† ††††††††††††††††††††††† †††††††† ††††††††

†††† Art, other valuable items (describe)†† †††††††† †††††††† ††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

†††† _____________________________________†††††††† †††††††††††††††

††††††††††††††††††††††††††††††††††††††††††† †††††††† †††††††† ††††††††

9.†† List any mortgages or other substan-†† †††††††† †††††††† ††††††††

†††† tial debts owed by you that are not††† †††††††† †††††††† ††††††††

†††† shown above.†††††††††††††††††††††††††† †††††††† †††††††† ††††††††

†††† ____________________________________†† †††††††† †††††††† ††††††††

†††† ____________________________________†† †††††††† †††††††† ††††††††

†††† ____________________________________†† †††††††† †††††††† ††††††††

†††††††††††††††††††††††††††††††††††††††††††

 

10.†† Life Insurance

††† Loans

Person†† Policy††††††††††† ††† Against

Company†† Death ValueCash Value Insured Owner†† Beneficiary††† Policy

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

 

11.†††††† List any contingent liabilities, litigation, etc.

_____________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________