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Information Form

By Alex Cunningham,2014-07-10 16:52
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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: __________________________________________________

     _____________________________________________________________________________

     _____________________________________________________________________________

     _____________________________________________________________________________

     _____________________________________________________________________________

     _____________________________________________________________________________

     _____________________________________________________________________________

     _____________________________________________________________________________

     _____________________________________________________________________________

     _____________________________________________________________________________

     _____________________________________________________________________________

     _____________________________________________________________________________

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