CLIENT DATA FORM FOR WILLS and POWER OF ATTORNEY Please complete this questionnaire. It is important that you complete ALL items so that we have the information needed to draft your document(s). If a question does not apply to you, write N/A in the appropriate blank. If you need more space, use extra sheets and specify the question you are referring to. If you need assistance in answering a question, call our office. All information will be held in strict confidence. DATE_____________________________ 1. State your full name:__________________________________________________________________________________ First Middle Last Any other name(s) you have used: Age _____, date of birth ____________, Social Security #______________ 2. Current address: ________________________________________________ (Street address) City: _______________________, County ______________________, Zip__________ 3. Current Marital status: ___Single ____ Divorced ___ Widowed _____ Married If you are married, state your spouse's full name: Spouse's address:__________________________________________________________ Please give the name of any prior spouses, if any, and the date the marriage ended: Name of ex-spouse_________________________________________________________ Date marriage ended__________ Name of ex-spouse_________________________________________________________ Date marriage ended__________ Name of ex-spouse_________________________________________________________ Date marriage ended__________ 4. If you have children, please give the following information: FULL NAME_________________________________________________________ ____Son ____ Daughter Age_____ Address____________________________________________________________________ County_________________________ FULL NAME_________________________________________________________ ____ Son ____ Daughter Age_____ Address____________________________________________________________________ County_________________________ FULL NAME_________________________________________________________ ____ Son ____ Daughter Age_____ Address____________________________________________________________________ County_________________________ FULL NAME_________________________________________________________ ____ Son ____ Daughter Age_____ Address____________________________________________________________________ County_________________________ FULL NAME_________________________________________________________ ____ Son ____ Daughter Age_____ Address____________________________________________________________________ County_________________________ FULL NAME_________________________________________________________ ____ Son ____ Daughter Age_____ Address____________________________________________________________________ County_________________________ 5. If any of your children are under the age of eighteen (18), state the full name, address and relationship (if any) of the person you wish to act as their custodian in the event of your death (in the case of a single parent) or in the case of the joint death of you and your spouse (if married). You should obtain the consent of that person(s) before executing your Will. Name_____________________________________________ Relationship____________________ Address_______________________________________________________________________ City _________________________ County__________________ State_______ Zip____________ If the person named above is unwilling or unable to serve as custodian, please list an alternative: Alternate 1: Name_____________________________________________ Relationship____________________ Address_______________________________________________________________________ City _________________________ County__________________ State_______ Zip____________ Alternate 2: Name_____________________________________________ Relationship____________________ Address_______________________________________________________________________ City _________________________ County__________________ State_______ Zip____________ 6. List the following information: a. Real estate owned by you in whole or in part: ADDRESS_____________________________________________________________ LEGAL DESCRIPTION ADDRESS______________________________________________________________ LEGAL DESCRIPTION ADDRESS______________________________________________________________ LEGAL DESCRIPTION b. Savings accounts, Checking Accounts, Certificates of Deposits, Money Market Accounts, Pension Plans, Profit Sharing Plans, 401(K) Plans, or other plans or accounts: TYPE_____________________________________ LOCATION__________________ ACCOUNT NUMBER____________________________ VALUE__________ TYPE_____________________________________ LOCATION__________________ ACCOUNT NUMBER____________________________ VALUE__________ TYPE_____________________________________ LOCATION__________________ ACCOUNT NUMBER____________________________ VALUE__________ TYPE_____________________________________ LOCATION__________________ ACCOUNT NUMBER____________________________ VALUE__________ TYPE_____________________________________ LOCATION__________________ ACCOUNT NUMBER____________________________ VALUE__________ TYPE_____________________________________ LOCATION__________________ ACCOUNT NUMBER____________________________ VALUE__________ TYPE_____________________________________ LOCATION__________________ ACCOUNT NUMBER____________________________ VALUE__________ c. Stocks, Bonds, Securities or other investment information: ________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 7. List life insurance information: a. Cash surrender value of any life insurance policies $___________ b. Death value of any life insurance policies $___________ c. Cash surrender value of life insurance on spouse $___________ d. Death value of life insurance policy on spouse $___________ e. Retirement Benefits or Annuities $___________ f. Retirement or Death Benefits from sources other than employment $___________ 8. Who is your life insurance agent? ________________________________________ 9. Do you have any transferable licenses (especially as to guns or business)? _ No _ Yes If yes, list the license(s): ___________________________________________________ 10. a. Generally, most MARRIED people provide that upon their death their property passes: (1) To surviving spouse. (2) If spouse predeceases you, your property will be divided in equal shares among all your living children. (3) If your spouse and one of your children predecease you, that child's share in your estate is distributed to his or her children (your grandchildren) in equal shares. b. Most UNMARRIED persons with children provide that upon their death, their property passes: (1) In equal shares to all your living children. (2) If one or more of your children predecease you, that child's share in your estate is distributed to his or her children (your grandchildren) in equal shares. IF YOU HAVE BEEN DIVORCED, DOES THE DECREE PROVIDE FOR ALIMONY OR CHILD SUPPORT AFTER DEATH? _____Yes ___ No ___ CHECK HERE IF YOU DO NOT WISH YOUR PROPERTY TO PASS IN THE MANNER SET FORTH ABOVE IN PARAGRAPH 8. DESCRIBE YOUR ALTERNATE PLAN: ________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ DO YOU WISH TO SPECIFICALLY EXCLUDE ANYONE FROM YOUR WILL? __ No __Yes IF YES, PLEASE SPECIFY:________________________________________________ 9. a. If you are UNMARRIED and presently have NO CHILDREN, list the names and addresses of the person(s) you wish to receive your property. (If more than one person is named, property will pass in equal shares to all listed below who survive you): FULL NAME____________________________________________________________ RELATIONSHIP__________ ADDRESS__________________________________________________________________ FULL NAME____________________________________________________________ RELATIONSHIP__________ ADDRESS__________________________________________________________________ FULL NAME____________________________________________________________ RELATIONSHIP__________ ADDRESS__________________________________________________________________ FULL NAME____________________________________________________________ RELATIONSHIP__________ ADDRESS__________________________________________________________________ b. If all the persons listed in 9a predecease you, list any alternative beneficiaries. FULL NAME____________________________________________________________ RELATIONSHIP__________ ADDRESS__________________________________________________________________ FULL NAME____________________________________________________________ RELATIONSHIP__________ ADDRESS__________________________________________________________________ 10. Many people make special provisions for family heirlooms, jewelry or other items of special value to friends or relatives. If you have such property and wish it left to a specific person, please complete the following: ITEM__________________________________________________________________ RECIPIENT _________________ SPECIAL IDENTIFYING FEATURES_________________________________________ ITEM__________________________________________________________________ RECIPIENT _________________ SPECIAL IDENTIFYING FEATURES_________________________________________ ITEM__________________________________________________________________ RECIPIENT _________________ SPECIAL IDENTIFYING FEATURES_________________________________________ ITEM__________________________________________________________________ RECIPIENT _________________ SPECIAL IDENTIFYING FEATURES_________________________________________ ITEM__________________________________________________________________ RECIPIENT _________________ SPECIAL IDENTIFYING FEATURES_________________________________________ 11. The person charged with administering your estate, paying taxes and other debts, marshalling, preserving, and managing your estate assets and property is called an EXECUTOR/EXECUTRIX. State the name and address of the person you wish to serve in this role along with any alternative choices. FULL NAME____________________________________________________________ RELATIONSHIP__________ ADDRESS__________________________________________________________________ FULL NAME____________________________________________________________ RELATIONSHIP__________ ADDRESS__________________________________________________________________ FULL NAME____________________________________________________________ RELATIONSHIP__________ ADDRESS__________________________________________________________________ 12. The person charged with executing your STATUTORY DURABLE POWER OF ATTORNEY is called an agent. State the name and address of the persons you wish to serve in this role, along with any alternative choices. WHEN WOULD YOU LIKE YOUR STATUTORY DURABLE POWER OF ATTORNEY to become effective? ___ immediately ____ upon disability or incapacity FULL NAME____________________________________________________________ RELATIONSHIP__________ ADDRESS__________________________________________________________________ Alternate 1: FULL NAME____________________________________________________________ RELATIONSHIP__________ ADDRESS__________________________________________________________________ Alternate 2: FULL NAME____________________________________________________________ RELATIONSHIP__________ ADDRESS__________________________________________________________________ Alternate 3: FULL NAME____________________________________________________________ RELATIONSHIP__________ ADDRESS__________________________________________________________________ 13. If you are requesting a DURABLE POWER OF ATTORNEY FOR HEALTH CARE, who would you like to receive copies of this document? FULL NAME____________________________________________________________ RELATIONSHIP__________ ADDRESS__________________________________________________________________ FULL NAME____________________________________________________________ RELATIONSHIP__________ ADDRESS__________________________________________________________________ FULL NAME____________________________________________________________ RELATIONSHIP__________ ADDRESS__________________________________________________________________ WHERE WILL YOU BE KEEPING THE ORIGINAL OF THE DURABLE POWER OF ATTORNEY FOR HEALTH CARE? ______________________________________________________________________________ ______________________________________________________________________________ State the name of the person you wish to make health care decisions for you upon your disability or incapacity. Also, list any alternate choices. FULL NAME____________________________________________________________ RELATIONSHIP__________ ADDRESS__________________________________________________________________ Alternate 1: FULL NAME____________________________________________________________ RELATIONSHIP__________ ADDRESS__________________________________________________________________ Alternate 2: FULL NAME____________________________________________________________ RELATIONSHIP__________ ADDRESS__________________________________________________________________ 14. If there is there any additional information you feel would assist us in Preparing your Will or Power of Attorney documents, please write it below: ADVISORS The following list should be completed and provided to your agents and named executors. It would assist me if you permit me to contact any insurance company or financial institution to determine the status of title and designation of beneficiaries. This should be done for each pension plan, IRA account, life insurance policy or annuity. Do I have your permission to contact such companies? ___ Yes ____No Accountant--Personal: ___________________________________________________________ Accountant-Business: ___________________________________________________________ Attorney-Personal: ______________________________________________________________ Attorney-Business: _____________________________________________________________ Banker/Trust Officer: ____________________________________________________________ Bank Name and Address: _________________________________________________________ Life Insurance Advisor: __________________________________________________________ Company Name and address: ______________________________________________________ Casualty Insurance Advisor:_______________________________________________________ Investment Advisor/Broker: _______________________________________________________ Name and Address:______________________________________________________________ Personal Physician: _____________________________________________________________ Business Associates: ____________________________________________________________ Other Advisors Not Listed Above: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ §§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§ TO BE COMPLETED ONLY BY ATTORNEY: Standard Will ______________________________________________________________ Physician's Directive _________________________________________________________ Will w/Special Instructions_____________________________________________________ Physician's Directive-Catholic Version___________________________________________ Codicil to a current Will _______________________________________________________ Health Care Power of Attorney __________________________________________________ Trust Provision_______________________________________________________________ Guardianship Provision________________________________________________________ Employment-based Pension Clause_______________________________________________ Statutory Durable Power of Attorney______________________________________________ Other ______________________________________________________________________ Uniform Transfer to Minors Clause_______________________________________________ ATTORNEY NOTES: