Information Form

Exchange Building • Suite 400

26 East Exchange St.

St. Paul, MN 55101

(651) 628-4998 Phone

(651) 222-7989 Facsimile

http://www.judithmrush.com

Judith M. Rush

Attorney at Law

ESTATE PLANNING AND WILL INFORMATION FORM

WHEN YOU HAVE COMPLETED THIS FORM, please return it to my office or bring it along to

your scheduled office conference. I rely upon the information you provide us to be accurate and

complete in all respects so that recommendations I make are appropriate for your situation.

1. Testator (Person(s) making will).

Name ______________________________________ Date of Birth ____________________

Social Security No. ___________________________ U.S. Citizen? Yes

? No ?

Spouse Name _______________________________ Date of Birth ____________________

Social Security No. ___________________________ U.S. Citizen? Yes ? No ?

Street Address______________________ Apt ____________ County ________________

City ________________________________ State __________ Zip ___________________

State of Residence ___________________________________________________________

Telephone Number H: ____________ w/Client ____________ w/Spouse _____________

2. Marriage.

a. Have you and your spouse signed a Premarital Agreement? Yes

? No ?

If you have, please bring a copy of it to the interview.

b. Have you or your spouse been divorced? Yes ? No ?

If so, please bring a copy of the divorce decree to the interview.

3. Children.

Please list ALL your children, including deceased children, children born out of wedlock, and

children you wish to omit from your estate plan.

Name of Child Date of Birth Address Child of

__________________________________________________________________________

Identify any child who is not a natural or adopted child of both you and your spouse.

a. Have any children received an advance on their inheritance or are any children financially

indebted to you? If so, please explain.

b. Is there any reason NOT to treat your children equally? If so, please explain.

c. Are any of the children under a disability?

d. Do you have any special concerns or objectives regarding your children?

e. Guardians. Who should be guardian of your minor children? (A guardian has physical and

legal control over your children until they reach the age of 18.)

Name: __________________________________________________________________

Address: ________________________________________________________________

Alternate Guardian: ________________________________________________________

Address: ________________________________________________________________

4. Personal Representative.

Who should be Personal Representative ("executor") of your estate? A Personal

Representative is responsible for probating your will, paying your debts, collecting your assets,

and settling your estate.

Name: _______________________________________________________________________

Relationship to you: _____________________________________________________________

Address: ______________________________________________________________________

Alternate Personal Representative: _________________________________________________

Relationship to you: _____________________________________________________________

Address: ______________________________________________________________________

5. Trusts.

If a trust is appropriate to include in your estate plan, who should be the trustee? A trustee is

the person or entity who is responsible for managing the assets placed into the trust. A trustee

manages the assets for your children or other beneficiaries until they reach specified ages. If you do not establish a trust, children inherit at age 18. You may name an individual, bank or

trust company, or both to act as your trustee.

Name: _____________________________________________________________________

Address: ___________________________________________________________________

Alternate Trustee: ____________________________________________________________

Address: ___________________________________________________________________

__________________________________________________________________________

6. Financial Inventory

Use approximate values under each person showing ownership of each asset. BRING

SUPPORTING DATA FOR EACH ASSET, i.e. bank statements, retirement reports, stock and

bond account reports, etc. NOTE: If you are entering into a revocable (living) trust, bring copies

of deeds to real estate you own.

ASSETS HUSBAND WIFE JOINT

Home

Other Real Estate

Checking Account

Savings Account

Money Market Account

Automobile

Personal Property

Stocks & Bonds

Closely Held Business Interest

Life Insurance (Face):

On husband's life

On wife's life

Retirement Accounts:

IRA

Pension

Profit Sharing/401k

Other Assets:

TOTAL

LIABILITIES HUSBAND WIFE JOINT

Home Mortgage

Other Mortgages

Debts To Family Members

Other Debts (describe):

TOTAL LIABILITIES

7. Beneficiary Designations:

a. Life Insurance:

Policy Name/Number Face Value Owner Insured Beneficiary

1.

2.

3.

4.

5.

b. Retirement Plans. Please list your retirement plans/IRAs; value of each and the beneficiary

of each. ? No ?. If so, who is the named beneficiary? c. Does your retirement plan have a death benefit? Yes

8. Personal Property.

Describe and give a value of any items of substantial value, such as automobiles, works of art,

jewelry, etc. Be sure to include any items listed on an insurance rider.

Description Approximate Value Personal Property ________________________ _________________________________

______________________________________ _________________________________

Automobiles _____________________________ _________________________________

______________________________________ _________________________________

Collectibles _____________________________ _________________________________

Jewelry ________________________________ _________________________________

Boats/Airplanes __________________________ _________________________________

Other: _________________________________ _________________________________

9. Safe Deposit Box. ? No ? If so, where? _________________________

Do you have a safe deposit box? Yes Does anyone else have access to your box? _______________________________________

10. Future Inheritances.

Do you expect any inheritance in the near future? If so please give details: ________________

__________________________________________________________________________

11. Financial Advisors.

Accountant: _________________________________________________________________

Address: ___________________________________________________________________

Telephone: __________________________________________________________________

Financial Advisor: ____________________________________________________________

Address: ___________________________________________________________________

Telephone: __________________________________________________________________

12. Primary Physician.

Who is your primary physician?

Name: _____________________________________________________________________

Address: ___________________________________________________________________

__________________________________________________________________________

13. Special Requests.

Special requests regarding funeral, cremation, or burial instructions are best handled by a

Letter of Instruction or other statement (separate from your will) to your family or other

responsible person. Organ donation is best handled in a Health Care Directive and noted on

the person’s driver’s license.

14. Discussion Issues.

We will discuss the following issues at the meeting:

• Current Will. Do you now have a will or revocable trust? If so, bring a copy to the

interview meeting.

• Predeceased Child. If any child should predecease parent, should his/her share pass

through to his/her children? If so, please indicate grandchildren, if any.

• Do you wish to include grandchildren born out of wedlock? Yes ? No ?

• Trusts. Do you wish to have a trust established for the benefit of your spouse and/or

children?

• Specific Gifts. Do you wish to make any specific bequests to charities or individuals?

• No Family Survives. How should your estate be distributed if your spouse and/or

children do not survive you? (For example: family, charity, etc.)

• If no Children. If you do not have children, to whom should your estate pass (beyond a

spouse, if any)?

• Health Care Directive. Are you interested in preparing a Health Care Directive

appointing someone to make health care decisions for you and/or stating your

preferences for health care? This document can also include instructions regarding

organ donation.

• Power of Attorney. Are you interested in preparing a Power of Attorney granting another

person the power to act on your behalf to manage your assets and pay your bills if you

become incompetent or unable to sign your name?

• Loan Guarantees. Have you guaranteed any loans for your children, grandchildren or

any other person? If so, bring details to meeting.

Health Care Directive

a. Agent. Name, address and telephone number of the person who you want to make health

care decisions if you cannot make them yourself:

________________________________________________________________________

b. Successor or Co-Agent’s name, address, and telephone number:

________________________________________________________________________

c. Successor or Co-Agent’s name, address, and telephone number:

________________________________________________________________________

d. If you have named co-agents, do you want the agents to ? act jointly or ? independently?

e. Do you have a Living Will to which you want to refer in the Health Care Directive?

Yes ? No ?. If yes, date of instrument: _____________________________________ .

f. Do you want directions as to what you want or do not want if you are in a terminal condition

(i.e. not expected to live more than 6 months)? Yes ? No ?. If you answered yes, please

provide us the specific language you want or you can approve language in the document.

g. Do you want to donate any organs upon your death? Yes ? No ?.

If yes, have you agreed in another document, e.g. drivers license, to make the donation?

Yes ? No ?.

h. Please indicate how you want the disposition of your remains after you die, e.g. cremation,

regular burial, etc.:

i. Do you have other living wills or health care powers of attorney forms which you want to

revoke? We recommend revocation to keep your wishes and desires clear.

j. Do you have any other instructions regarding your health care, living arrangements, burial,

etc.? If so, please indicate:

Note any questions you have here: __________________________________________________

_____________________________________________________________________________

DOCSFORD

Information Form