Workseet

---

* What is your full legal name:

Names / spellings used or known by:

What is your physical address:

Mailing address (if different):

Email address you check the most often:

Please list any additional email addresses:

Best day time phone number:

Best night time phone number:

Please list any additional phone numbers:

What is Your Date of Birth:

Social Security Number:

What type of work do you do:

Who is your employer:

What is your marital status:

If married, name of your spouse :

If domestic partner, name of partner:

Date of all marriages:

Date of all legal partnerships:

Date of all divorces:

Do you intend this estate plan to include your spouse's/partner's property or wishes :

yes

no

Does your spouse/partner know you are putting together an estate plan:

yes

no

Are you a U.S. citizen:

yes

no

Is your spouse/partner a U.S. citizen:

yes

no

If you or your spouse/partner are not U.S. citizens, of which country are you:

Please include the following information regarding any REAL ESTATE that you own include, Address, Cost Basis, Fair Market Value, and Dept:

Please include the following information regarding any STANDARD BANK ACCOUNTS that you own, include Financial Institution, Type of Account, and Approximate Balance:

Please include the following information regarding any MISCELLANEOUS INVESTMENTS or BUSINESS ENTITIES that you own (this would include oil, gas, and mineral rights, promissory notes, etc.) Type of Investment / Entity, Name oe Affiliation, and Approximate value:

Please include the following information regarding any NON-QUALIFIED INVESTMENT ACCOUNTS that you own. (Note that these are after-tax, and do not include 401 (k) s, IRAs, etc.) Financial Institution, Type of Account, and Approximate Value:

Please include the following information regarding any QUALIFIED RETIREMENT ACCOUNTS that you own. (Note that these do include 401 (k) s, IRAs, pensions, etc.) Financial Institution, Type of Account, and Approximate Value:

Please include the following information regarding any LIFE INSURANCE POLICIES that you own, Company Name, Insured, Beneficiaries, Death Benefit, and Cash Value:

Please include any information regarding any assets or property that did not fit above, or was not included:

Who would you like to serve as the successor TRUSTEE / EXECUTOR of your estate? If that individual is unable or unwilling, who would you like to serve in their place? Please list any additional successor trustees as well. Lastly, please note if you would like any of your successor trustees to act together as co-trustees:

If you have any minor children, who would you like to serve as the GUARDIAN of your minor children? If that individual is unable or unwilling, who would you like to serve in their place? Please list any additional successor guardians as well. Lastly, please note if you would like any of your guardians to act together as co-guardians

Who would you like to serve as your AGENT / POWER OF ATTORNEY FOR YOUR PERSONAL AND NON­ TRUST FINANCIAL AFFAIRS should you becomes incapacitated? If that individual is unable or unwilling, you would you like to serve in their place? Please list any additional successor agents as well. Lastly, please note if you would like any of your agents to act together as co-agents:

Who would you like to serve as your AGENT FOR YOUR HEALTH CARE AND MEDICAL AFFAIRS should you becomes incapacitated? If that individual is unable or unwilling, you would you like to serve in their place? Please list any additional successor agents as well. Lastly, please note if you would like any of your agents to act together as co-agents:

Would you like your children to be your primary beneficiaries in equal shares?

yes

no

If you would like your children to be your primary beneficiaries in equal shares, if one or more of your children were to already be deceased upon your death, to whom would you like that child's share to go to (check one)?

To any grandchildren parented by that deceased child (if any).

To your surviving children.

You will most likely want your estate to be used to provide for a reasonable standard of living for your child; this includes health, education, maintenance, and support. When would you like each child to stop receiving such support (check one)? Upon beginning to receive the rest of their inheritance (noted below) Upon attaining a specific age Upon occurrence of some other events or criteria: I do not want this support to stop I do not want provide this Other

Assuming your children’s health, education, maintenance, and support are already being taken care of (as noted above), when would you like them to begin to receive the rest of their inheritance? Outright, upon your death in one lump sum upon each child attaining the age of In equal payments upon each child attaining different ages:

If you have chosen a criteria not related to age, what would you like done with that beneficiary’s share should the beneficiary not meet that criteria? Distribute the share outright at age Distribute the share as if the child was deceased () Distribute the share to another beneficiary: Other

It is typically beneficial from an income tax perspective to not retain income inside of a trust. So there may be a situation where the trust is earning rental or interest income before your beneficiaries would otherwise receive their inheritance. Do you have a problem with your beneficiaries receiving any income generated by the trust outright, thus potentially creating a lower income tax liability on the estate? No, go ahead and distribute it. Yes, do not distribute income until

Should there ever be an occurrence where a grandchild were to receive a portion of your estate (if their parent I your child were to be deceased prior to distribution), would you like your estate distributed to them in the same manner as your children? YES No, I’d like to distribute it as follows

If you do not have any children, or If you would like your estate distributed in a manner other than what has been described above, to whom, and how would you like your estate distributed? YES No, I’d like to distribute it as follows

If all of the above mentioned beneficiaries were to pre-decease you. That is to say, if all of your conceivable beneficiaries were to not be alive at the time of the distribution of your estate, where would you like your estate to go (note that this would only be as a result of an incredibly minute probability)? To your closest surviving family To a charity or other organization

State any specific concerns (not already mentioned) that you have regarding the distribution of your estate:

The "End-Of-Life” decision relates to how you would like to be medically treated should you be in situation where you physical body is unable to sustain itself, and without medical, life-sustaining support, death or a persistent vegetative state would be imminent. Which of the following statements best describes your feelings? I do not wish to prolong my life if I am in an irreversible and terminal or vegetative state. I want the ultimate decision to cease treatment to be made by my attending physician. I do not wish to prolong my life if I am in an irreversible and terminal or vegetative state. I want the ultimate decision to cease treatment to be made by my acting healthcare agent (as noted above). I wish every effort to be made to prolong my life.

Do you wish to donate your organs or tissue for transplantation or educational purposes?

yes

no

MISCELLANEOUS ISSUES / NOTES Please write down any notes or describe any other issues you would like to discuss further: