Estate Planning Data Gathering-2021

1
Client Name
First Name and Middle Initial
Middle Name
Last Name
2
Client Date of Birth
Date
Month
Day
Year
3
Client Email
example@example.com
4
Client Phone Number
Area Code
Phone Number
5
Spouse's Name
First Name and Middle Initial
Middle Name
Last Name
6
Spouse Date of Birth
Date
Month
Day
Year
7
Spouse Email
example@example.com
8
Spouse Phone Number
Area Code
Phone Number
9
Address
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
10
Name of TrustExample: The Smith Family Trust, The Joe and Jane Smith Family Trust (can also use Living Trust in place of Family Trust)
11
Primary BeneficiariesThe main people who will receive your estate
First Name
Last Name
Age
Relationship
%
#1
#2
#3
#4
#5
#6
#1
#2
#3
#4
#5
#6
First Name
Last Name
Age
Relationship
%
First Name
Last Name
Age
Relationship
%
First Name
Last Name
Age
Relationship
%
First Name
Last Name
Age
Relationship
%
First Name
Last Name
Age
Relationship
%
First Name
Last Name
Age
Relationship
%
1 of 6
12
Trustee(s)Who do you want to manage your estate when you are BOTH gone or incapable of doing so?
First Name
Last Name
Relationship
Primary
Contingent
Primary
Contingent
First Name
Last Name
Relationship
First Name
Last Name
Relationship
1 of 2
13
Do you have children under the age of 18?
YESNO
14
Guardians for Dependent ChildrenWho would you want to care for your children when you are BOTH gone or incapable of doing so?
First Name
Last Name
Relationship
Primary
Contingent
Primary
Contingent
First Name
Last Name
Relationship
First Name
Last Name
Relationship
1 of 2
15
Is there anyone that you would like to DISINHERIT from your estate?
YESNO
16
Who would you like disinherited?
First Name
Last Name
Relationship
#1
#2
#3
#1
#2
#3
First Name
Last Name
Relationship
First Name
Last Name
Relationship
First Name
Last Name
Relationship
1 of 3
17
Is there any other "custom trust"Example: Unequal distributions, certain language as to who gets what, when and how or age distributions
YESNO
18
Custom language
Huge
Large
Normal
Small
Ok
Ok
19
Financial Powers of AttorneyWho can pay your bills and oversee your finances when you are BOTH gone or incapable of doing so?
First Name
Last Name
Relationship
Primary
Contingent
Primary
Contingent
First Name
Last Name
Relationship
First Name
Last Name
Relationship
1 of 2
20
Health Care Powers of AttorneyWho can make medical decisions when you are BOTH gone or incapable of doing so?
First Name
Last Name
Relationship
Phone
Address
Email
Primary
Contingent
Contingent
Contingent
Primary
Contingent
Contingent
Contingent
First Name
Last Name
Relationship
Phone
Address
Email
First Name
Last Name
Relationship
Phone
Address
Email
First Name
Last Name
Relationship
Phone
Address
Email
First Name
Last Name
Relationship
Phone
Address
Email
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21
Close to Death/End of Life (Choose EITHER Box 1 OR the other boxes below) If you choose Box 1 then continue on. If you choose something other, then check all the boxes that apply.If I am (a) close to death where tube feeding and/or life support would only postpone the moment of my death, and/or (b) unconscious and it is highly unlikely that I will ever regain consciousness again, and/or (c) I have a progressive illness that will be fatal and is in an advanced stage, and I am consistently and permanently unable to communicate by any means, swallow food and water safely, care for myself and recognize loved ones, and it is very unlikely that my condition will substantially improve, then I request that the following actions be taken, or not taken, as indicated by a marked box:
I Choose Not To Prolong My Life if (a) I have an incurable and irreversible condition that will likely result in my death within a short time, and/or (b) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, and/or (c) the apparent risks and burdens of treatment would outweigh the expected benefits.
I want tube feeding/hydration
I want no tube feeding/hydration
I want life support
I want no life support
As my Agent recommends
As my Physician recommends
22
Financial Inventory

1. PERSONAL REAL ESTATE — Real Property Personally Owned
2. SECURED REALTY NOTE INTERESTS — Personally Owned
3. PROMISSORY NOTE INTERESTS (Non-Realty) — Secured / Unsecured
4. ENTITY BUSINESS INTERESTS — Closely Held
5. CASH ACCOUNTS — Bank & Money Market Accounts, CDs (etc.)
6. REGISTERED SECURITIES — Mutual Funds / Managed Investment Accounts / ETFs
7. STOCKS & BONDS — Listed on a Public Exchange
8. ANNUITY CONTRACTS — With Death Benefits
9. LIFE INSURANCE CONTRACTS — Personally Owned
10. INDIVIDUAL RETIREMENT ACCOUNTS — Traditional & Roth IRAs
11. RETIREMENT PLANS — 401(K), 403(B), Deferred Comp. (etc.)
12. MOTOR VEHICLES — Vintage Cars, RVs, Mobile Homes (etc.)
23
Address of PRIMARY home
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
24
Do you have any additional homes or land?
YESNO
25
Please list address or property description including County where they are located
Huge
Large
Normal
Small
Ok
Ok
26
Secured Realty Note's
Note 1
Note 2
Note 3
Note 4
Payor Name
Type(Sec/Unsec)
Date of Origin
Place of Origin
Original Value
Payor Name
Type(Sec/Unsec)
Date of Origin
Place of Origin
Original Value
Note 1
Note 2
Note 3
Note 4
Note 1
Note 2
Note 3
Note 4
Note 1
Note 2
Note 3
Note 4
Note 1
Note 2
Note 3
Note 4
Note 1
Note 2
Note 3
Note 4
1 of 5
27
Promissory Notes
Note 1
Note 2
Note 3
Note 4
Payor Name
Type (Sec/Unsec)
Date of Origin
Place of Origin
Original Value
Payor Name
Type (Sec/Unsec)
Date of Origin
Place of Origin
Original Value
Note 1
Note 2
Note 3
Note 4
Note 1
Note 2
Note 3
Note 4
Note 1
Note 2
Note 3
Note 4
Note 1
Note 2
Note 3
Note 4
Note 1
Note 2
Note 3
Note 4
1 of 5
28
Businesses
Business 1
Business 2
Business 3
Business 4
Name
Type (LLC, Inc.)
Street Address
City/State/Zip
ID/Acc. Number
Date of Origin
Name
Type (LLC, Inc.)
Street Address
City/State/Zip
ID/Acc. Number
Date of Origin
Business 1
Business 2
Business 3
Business 4
Business 1
Business 2
Business 3
Business 4
Business 1
Business 2
Business 3
Business 4
Business 1
Business 2
Business 3
Business 4
Business 1
Business 2
Business 3
Business 4
Business 1
Business 2
Business 3
Business 4
1 of 6
29
Accounts
Account 1
Account 2
Account 3
Account 4
Account 5
Account 6
Institution
Type (Check./Sav)
Street Address
City/State/Zip
Estimated Value
Account Number
Institution
Type (Check./Sav)
Street Address
City/State/Zip
Estimated Value
Account Number
Account 1
Account 2
Account 3
Account 4
Account 5
Account 6
Account 1
Account 2
Account 3
Account 4
Account 5
Account 6
Account 1
Account 2
Account 3
Account 4
Account 5
Account 6
Account 1
Account 2
Account 3
Account 4
Account 5
Account 6
Account 1
Account 2
Account 3
Account 4
Account 5
Account 6
Account 1
Account 2
Account 3
Account 4
Account 5
Account 6
1 of 6
30
SecuritiesNON-Retirement account's (NON-IRA's)
Account 1
Account 2
Account 3
Account 4
Account 5
Account 6
Institution
Street Address
City/State/Zip
Type
Value
Account Number
Owned By
Institution
Street Address
City/State/Zip
Type
Value
Account Number
Owned By
Account 1
Account 2
Account 3
Account 4
Account 5
Account 6
Account 1
Account 2
Account 3
Account 4
Account 5
Account 6
Account 1
Account 2
Account 3
Account 4
Account 5
Account 6
Account 1
Account 2
Account 3
Account 4
Account 5
Account 6
Account 1
Account 2
Account 3
Account 4
Account 5
Account 6
Account 1
Account 2
Account 3
Account 4
Account 5
Account 6
Account 1
Account 2
Account 3
Account 4
Account 5
Account 6
1 of 7
31
Bonds
Bond1
Bond 2
Bond 3
Bond 4
Bond 5
Bond 6
Institution
Street Address
City/State/Zip
Type
Value
Certificate Number
Owned By
Institution
Street Address
City/State/Zip
Type
Value
Certificate Number
Owned By
Bond1
Bond 2
Bond 3
Bond 4
Bond 5
Bond 6
Bond1
Bond 2
Bond 3
Bond 4
Bond 5
Bond 6
Bond1
Bond 2
Bond 3
Bond 4
Bond 5
Bond 6
Bond1
Bond 2
Bond 3
Bond 4
Bond 5
Bond 6
Bond1
Bond 2
Bond 3
Bond 4
Bond 5
Bond 6
Bond1
Bond 2
Bond 3
Bond 4
Bond 5
Bond 6
Bond1
Bond 2
Bond 3
Bond 4
Bond 5
Bond 6
1 of 7
32
Annuity Contracts
Annuity 1
Annuity 2
Annuity 3
Annuity 4
Annuity 5
Annuity 6
Institution
Street Address
City/State/Zip
Type (IRA, Joint)
Value
Account Number
Owned By
Institution
Street Address
City/State/Zip
Type (IRA, Joint)
Value
Account Number
Owned By
Annuity 1
Annuity 2
Annuity 3
Annuity 4
Annuity 5
Annuity 6
Annuity 1
Annuity 2
Annuity 3
Annuity 4
Annuity 5
Annuity 6
Annuity 1
Annuity 2
Annuity 3
Annuity 4
Annuity 5
Annuity 6
Annuity 1
Annuity 2
Annuity 3
Annuity 4
Annuity 5
Annuity 6
Annuity 1
Annuity 2
Annuity 3
Annuity 4
Annuity 5
Annuity 6
Annuity 1
Annuity 2
Annuity 3
Annuity 4
Annuity 5
Annuity 6
Annuity 1
Annuity 2
Annuity 3
Annuity 4
Annuity 5
Annuity 6
1 of 7
33
Life Insurance
Policy1
Policy 2
Policy 3
Policy 4
Policy 5
Policy 6
Institution
Street Address
City/State/Zip
Type (Term, Whole Life)
Death Benefit
Cash Value
Account Number
Owned By
Institution
Street Address
City/State/Zip
Type (Term, Whole Life)
Death Benefit
Cash Value
Account Number
Owned By
Policy1
Policy 2
Policy 3
Policy 4
Policy 5
Policy 6
Policy1
Policy 2
Policy 3
Policy 4
Policy 5
Policy 6
Policy1
Policy 2
Policy 3
Policy 4
Policy 5
Policy 6
Policy1
Policy 2
Policy 3
Policy 4
Policy 5
Policy 6
Policy1
Policy 2
Policy 3
Policy 4
Policy 5
Policy 6
Policy1
Policy 2
Policy 3
Policy 4
Policy 5
Policy 6
Policy1
Policy 2
Policy 3
Policy 4
Policy 5
Policy 6
Policy1
Policy 2
Policy 3
Policy 4
Policy 5
Policy 6
1 of 8
34
IRA's
IRA 1
IRA 2
IRA 3
IRA 4
IRA 5
IRA 6
Institution
Street Address
City/State/Zip
Type
Value
Account Number
Institution
Street Address
City/State/Zip
Type
Value
Account Number
IRA 1
IRA 2
IRA 3
IRA 4
IRA 5
IRA 6
IRA 1
IRA 2
IRA 3
IRA 4
IRA 5
IRA 6
IRA 1
IRA 2
IRA 3
IRA 4
IRA 5
IRA 6
IRA 1
IRA 2
IRA 3
IRA 4
IRA 5
IRA 6
IRA 1
IRA 2
IRA 3
IRA 4
IRA 5
IRA 6
IRA 1
IRA 2
IRA 3
IRA 4
IRA 5
IRA 6
1 of 6
35
Retirement Plans
Plan 1
Plan 2
Plan 3
Plan 4
Plan 5
Plan 6
Institution
Street Address
City/State/Zip
Type
Value
Account Number
Institution
Street Address
City/State/Zip
Type
Value
Account Number
Plan 1
Plan 2
Plan 3
Plan 4
Plan 5
Plan 6
Plan 1
Plan 2
Plan 3
Plan 4
Plan 5
Plan 6
Plan 1
Plan 2
Plan 3
Plan 4
Plan 5
Plan 6
Plan 1
Plan 2
Plan 3
Plan 4
Plan 5
Plan 6
Plan 1
Plan 2
Plan 3
Plan 4
Plan 5
Plan 6
Plan 1
Plan 2
Plan 3
Plan 4
Plan 5
Plan 6
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36
Motor Vehicles
1
2
3
4
5
6
Vehicle Desc.
Year/Make
Model/Type
VIN
Value
Vehicle Desc.
Year/Make
Model/Type
VIN
Value
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
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37
Any other information that you would like to include?
Huge
Large
Normal
Small
Ok
Ok
Should be Empty:

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