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Estate Mate. Your Partner For Estate Planning
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Burial Wishes
Estate Value
Life Insurance
CLIENT INFORMATION
[Strictly Confidential]
Legal Name:
Other Names used:
Address:
County:
E-Mail:
Telephone: (home)
(Work)
(Cell)
Date of Birth:
Social Security No.
Business/Employer:
Marital Status:
Never married
Divorced
Widowed
Married
If married, name of Spouse:
US citizen?
Yes
No
If no, what nationality:
Children
Yes
No
Children
AGE or DOB
+
Number of grandchildren:
Range of Ages:
Any deceased children?
Yes
No
If yes, name:
If yes, survived by issue?
Yes
No
If yes, name(s):
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MORE QUESTIONS
Do any of your beneficiaries have a learning disability, special educational, medical or physical needs?
Yes
No
Do you have any relatives (other than children) who depend on you for all or part of their support?
Yes
No
Do you think any of your beneficiaries have special problems with spouses, drugs, alcohol or handling money?
Yes
No
Do you wish to disinherit any of your children, grandchildren or any other close relative?
Yes
No
If a named beneficiary dies before you, do you want the assets to go to that beneficiary’s issue?
Yes
No
Do you want assets passing to your beneficiaries to be held in trust until a specific age or ages?
Yes
No
Do you expect to inherit substantial assets ($100,000 +)?
Yes
No
Do you have an existing Will?
Yes
No
Have you ever executed a trust (either revocable or irrevocable)?
Yes
No
Have you ever filed a Federal Gift Tax Return?
Yes
No
Do you have an existing General Power of Attorney?
Yes
No
Do you currently hold any assets in Joint Tenancy with another person?
Yes
No
What would you like the name of your trust to be?
The name of the person(s) that you want to be the decision maker concerning your estate upon your death:
The name of the person(s) that you want to raise a child that is under 18 (if applicable) (i.e., guardians):
The name of the person(s) that you want to make any major medical decisions on your behalf(i.e., attorney-in-fact/representatives) (Also include addresses and phone numbers for each):
In general, state how you want your estate distributed among your beneficiaries?
State any specific concerns (not already mentioned) that you have regarding the distribution of your estate:
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BURIAL WISHES
At my death, I wish to be:
Cremated
Buried.
If cremation, I would like my ashes disposed as follows:
If buried, I would like my remains interred as follows:
I have already made arrangements at:
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ESTIMATED* VALUE OF ESTATE
* Use best guess; this can be a “ballpark” estimate.
** Do not show benefits which will terminate at death (e.g., pension, social security, etc.).
Value of Life Insurance policies will be listed separately on the next page.
TYPE OF ASSET:
REAL ESTATE
(fair market value, less loans)
ESTIMATED VALUE
$
SECURITIES:
(stocks, bonds, mutual funds)
$
CASH TYPE ASSETS:
(cash, annuities, notes due you)
$
BUSINESS INTERESTS:
(sole proprietorship, partnerships, closely held corporation, etc.)
$
RETIREMENT PLANS:
(IRA, 401k, etc.**)
$
VEHICLES:
(autos, R.V., boat)
$
PERSONAL PROPERTY:
(jewelry, furniture, antiques)
$
TOTAL
TOTAL
$
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LIFE INSURANCE
(do not include accidental death policies)
"Cash Value" use best estimate (term policies normally have no cash value)
"Face Value" is the amount payable at death
COMPANY
CASH VALUE
$
FACE VALUE
$
BENEFICIARY
COMPANY 2
CASH VALUE
$
FACE VALUE
$
BENEFICIARY
COMPANY 3
CASH VALUE
$
FACE VALUE
$
BENEFICIARY
COMPANY 4
CASE VALUE
$
FACE VALUE
$
BENEFICIARY
COMPANY 5
CASH VALUE
$
FACE VALUE
$
BENEFICIARY
COMPANY 6
CASH VALUE
$
FACE VALUE
$
BENEFICIARY
Submit
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