EP Personal Data

Personal Data for Estate Planning
Are you married?*

Full Name

First NameLast Name
Date of Birth

MonthDayYear
Spouse 1's Name

First NameLast Name
Spouse 1's Date of Birth

MonthDayYear
Spouse 2's Name

First NameLast Name
Spouse 2's Date of Birth

MonthDayYear
Date of Marriage

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number
Business Phone
E-mail Address
example@example.com
Spouse 1 Mobile Number
Spouse 2 Mobile Number
Spouse 1 E-mail Address
example@example.com
Spouse 2 E-mail Address
example@example.com

Other Beneficiaries, including charities (Name, relationship, location, DoB if minor)

Do you have an existing Will?
Does Spouse 1 have an existing Will?
Does Spouse 2 have an existing Will?
Do you have an existing Trust?
Does Spouse 1 have an existing Trust?
Does Spouse 2 have an existing Trust?
Do you currently have a Prenuptial Agreement?
If yes to any of the questions on this page, please provide us with a copy of such document(s) or bring them with you to your consultation

Cancelof

Describe your objectives:
A. Estate, including specific charitable gifts or bequests. For example, disregarding tax implications, do you want your spouse to receive the balance of your estate? Outright or in trust? Upon the death of the surviving spouse, is the balance of the estate to pass to your children? Outright or in trust? At what ages should your children receive their share of the estate?
B. Family, including lifetime gifts or bequests to family members and others.
C. Are there any other items you would like to have incorporated in your estate plan?

Designations
Who do you want to be your personal representative?
If that person predeceases you or fails to serve as personal representative, who do you want to be your alternate personal representative?
Who will be the personal representative for Spouse 1?
If that person predeceases Spouse 1 or fails to serve as personal representative, who will be Spouse 1's alternate personal representative?
Who will be the personal representative for Spouse 2?
If that person predeceases Spouse 2 or fails to serve as personal representative, who will be Spouse 2's alternate personal representative?
If applicable, who will serve as Trustee for you?
Other
If applicable, who will serve as guardian of your minor children?
Other
Who will serve as attorney-in-fact under a durable power of attorney (if desired)?
Other
Who will serve as health care surrogate (person to make medical decisions)?
Other

PRIOR MARRIAGES: If you were previously married, describe any continuing obligations under the divorce decree or marital settlement agreement, and provide us with a copy of such divorce decree or marital settlement agreement.
PRIOR MARRIAGES: If Spouse 1 or Spouse 2 were previously married, describe any continuing obligations under the divorce decree or marital settlement agreement, and provide us with a copy of such divorce decree or marital settlement agreement.
COMMUNITY PROPERTY: Generally all property acquired by spouses during their marriage from earnings of either spouse, while domiciled in a community property state, as well as property located in a community property state and acquired during marriage, is owned equally by them and is called community property. If you or your spouse have resided, during your marriage, in any community property law state(s) (such as Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, or Wisconsin), specify the name of the state(s) and dates of residence.
DOMICILE: If your employment, vacation, or other demands require that you spend more than a nominal amount of time in another state or country, you may be deemed a domiciliary of that jurisdiction for estate tax purposes. If you feel that the question may apply to you, set forth immediately below the name of the state or county, dates you were or will be present in such jurisdiction, where you vote, where you register your automobile, and property owned in such jurisdiction.

MISCELLANEOUS: Please indicate whether each of the below is applicable and provide details and requested documentation in the spaces where indicated below.


1. Have you or your spouse made any gifts exceeding $10,000.00 per year to any person or created any trusts? (supply copies of gift tax returns and trusts)
2. Do you or your spouse have a power of appointment or other interests under a Will or Trust of another person? (supply copy of document, if available)
3. If you or your spouse has any prospective inheritances give source and estimated amount.
4. If you or your spouse are or were employed, give details of any pension plans or other employee benefits to which you are or may be entitled.
5. If you or your spouse are self-employed or a member of a partnership, give details of any contracts or commitments to sell such interest at death or retirement, as well as any retirement plans or other benefits that will be payable by reason of your death. (supply copies of any pertinent documents)
6. If you or your spouse own stock in a closely-held corporation, give details of any stock redemption agreements, stock options, salary continuation, or other deferred compensation plans that may be applicable to you (supply copies of documents)
7. Are you receiving or will you receive an annuity? If Yes, to whom will the payments be made? How long will payments be made? Duration: If fixed term, for how long? Amount of each payment?
8. Have you ever filed a corporate or partnership tax return? If Yes, please provide a copy of the last one filed with the IRS.
9. Have you ever filed a gift tax return (IRS Form 709)? If Yes, please provide a copy of the last one filed with the IRS.
10. Do you have relatives dependent upon you for support?
11. Do you hold stock in a closely-held corporation?
12. Do you have any medical issues of which we should be aware for planning purposes? If Yes, explain.
13. Do you own any property in a jurisdiction other than Florida? If Yes, describe including which jurisdiction.
14. Do you wish to be cremated or otherwise have special burial directions? If Yes, please provide details regarding your desired disposition of your remains.
15. Do you have any concerns that one or more of your beneficiaries will not behave responsibly with money that you give them?
16. Do you have any children or grandchildren attending private school, college, or graduate school?
17. Is any member of your family disabled and receiving medical benefits from State or Federal government?

Provide details (indicate the number of the applicable questions from above before each response)

Professional Advisors

	Name and Firm	Address/Phone Number
Attorney(s)
Financial Consultant
Accountant
Insurance Agent
Trust Officer
Other

Assets

	Estimated Market Value
Real Estate: Residence
Real Estate: Vacation Home
Other Real Estate
Stocks
Bonds and Notes
Value of Business Assets if Self-Employed or interest in partnership or closely-held corporation
Savings Account, Savings Certificates, Savings Bonds, Money Market, and Cash
Value of interest in an Estate or Trust
Interest in Profit Sharing or Retirement Plans or Keogh Plans
Independent Retirement Plan (IRA)
Interest in Valuable Stamp, Coin or Art Collection or Antiques
Annuities and Pensions
Miscellaneous Assets
Motor Vehicles
TOTAL ASSETS
LESS MORTGAGES, LOANS, AND OTHER LIABILITIES
NET ASSETS

Type a question

	Estimated Market Value	Spouse 1	Spouse 2	Joint
Real Estate: Residence
Real Estate: Vacation Home
Other Real Estate
Stocks
Bonds and Notes
Value of Business Assets if Self-Employed or interest in partnership or closely-held corporation
Savings Account, Savings Certificates, Savings Bonds, Money Market, and Cash
Value of interest in an Estate or Trust
Interest in Profit Sharing or Retirement Plans or Keogh Plans
Independent Retirement Plan (IRA)
Interest in Valuable Stamp, Coin or Art Collection or Antiques
Annuities and Pensions
Miscellaneous Assets
Motor Vehicles
TOTAL ASSETS
LESS MORTGAGES, LOANS, AND OTHER LIABILITIES
NET ASSETS

Profit Sharing, IRA, Pension Plans, 401k, etc.

	Owner	Description	Beneficiary	Current Value
1
2
3
4
5

Life Insurance, Long Term Care Insurance, Disability insurance, Liability Insurance

	Type of Insurance	Face Amount of Insurance	Owner	Primary Beneficiary	Secondary Beneficiary	Death Benefit?
1
2
3
4
5
6

I hereby acknowledge that Leuchtman Law, will prepare and make its recommendations relating to my estate planning and asset-protection planning based primarily upon the information provided to it pursuant to this questionnaire. I further acknowledge that it is our responsibility to advise Leuchtman Law of any material changes in my financial condition which occur subsequent to the date hereof.
We hereby acknowledge that Leuchtman Law, will prepare and make its recommendations relating to our estate planning and asset-protection planning based primarily upon the information provided to it pursuant to this questionnaire. We further acknowledge that it is our responsibility to advise Leuchtman Law of any material changes in our financial condition which occur subsequent to the date hereof.
Name: Full Name*
Date: Date*
Signature: Signature*
Spouse 1: Full Name*
Date: Date*
Signature Spouse 1: Signature*
Spouse 2: Full Name*
Date: Date*
Signature Spouse 2: Signature*
Should be Empty:

	Name	Son or Daughter?	Address	Birthdate (if minor)	Email	Mobile Phone	Has Spouse?	Has Children?
1
2
3
4
5
6

	Name	Son or Daughter?	Address	Birthdate (if minor)	Email	Mobile Phone	Has Spouse?	Has Children?
1
2
3
4
5
6

Personal Data for Estate Planning

Describe your objectives:

Designations

Assets