Estate Planning - Lommen Abdo Law Firm

1. Personal Data

Full Name:

Present Address:


City:		State:
Zip:		County:

Phone:

Home:
Business:
Cell:
Fax:

E-mail Address:

Date of Birth:

(MM/DD/YYYY)

Citizenship:

Social Security Number:

(XXX-XX-XXXX)

Occupation:

Employer and Address:

Any serious
health/disability issues:

2. Spouse

Full Name:

Present Address:


City:		State:
Zip:		County:

Phone:

Home:
Business:
Cell:
Fax:

E-mail Address:

Date of Birth:

(MM/DD/YYYY)

Citizenship:

Social Security Number:

(XXX-XX-XXXX)

Occupation:

Employer and Address:

Any serious
health/disability issues:

3. Other Miscellaneous Personal

Date and Place of Marriage:

Out of State Property:

Prior Marriage:

You:
Spouse:

If married, is either spouse not a U.S. Citizen?	Yes No
While married, did either spouse live in a community property state?	Yes No Don't Know

4. Children

Full Name	Address	Birth Date (MM/DD/YYYY)	Child of Husband, Wife or Both

5. Other dependents or relatives to be included

Full Name (and Spouse)	Address	Birth Date (MM/DD/YYYY)

6. Other persons or charities you wish included

Name	Address

7. If you, anyone in your family, or a dependent suffers from any physical or mental incapacity, please specify

8. Personal Representatives

Name	Address	Relationship	Phone Number

	Do you wish to require a bond?
	Do you wish to have Personal Representative paid?

9. Guardians

Name	Address	Relationship	Phone Number

Do you wish the inheritance to be restricted beyond the child reaching age 18?

Yes (complete Section #10)
No (complete Section #11)

10. Trustees

You should answer «Yes» to question in section #9 to be able to fill these fields in.

Name	Address	Relationship	Phone Number

Separate Trust?
Pot Trust?
Until Age(s):

11. Custodian

You should answer «No» to question in section #9 to be able to fill these fields in.

Name	Address	Relationship	Phone Number

12. Health Care Power of Attorney - Agent

Name	Address	Relationship	Phone Number

13. Financial (Statutory) Power of Attorney

Name	Address	Relationship	Phone Number

14. Is there anyone you specifically do not want included in your estate plan?

15. If all of your beneficiaries die before your assets are distributed, who should receive the estate?

One-half each side of family:
Other:

16. Balance Sheet: General: describe value to nearest $1,000 basis, and ownership as between husband, wife or joint (with right of survivorship).

FINANCIAL INFORMATION
ASSETS	AMOUNTS
ASSETS	WIFE	HUSBAND	JOINT
Cash/Checking/Savings
Notes Receivable
Real Estate/Home
Real Estate/Other
Stocks/Bonds
Money Market Funds/CDs
Partnership Interest
Sole Proprietorship Interests
Retirement Plans
Personal Property/Collections
Life Insurance Face Amounts
Life Insurance Cash Surrender Value
Funeral/Burial (Insurance/Prepaid Package)
Long Term Care Insurance
Anticipated Inheritance
Other Assets ^* ^*e.g. Frequent flyer miles, season tickets, etc.
Total Assets

LIABILITIES	AMOUNTS
LIABILITIES	WIFE	HUSBAND	JOINT
Real Estate Mortgage Payable
Loans Payable
Accounts Payable
Loans Against Life Insurance
Other Debts
Total Liabilities
NET ESTATE

Net Estate (Net Worth):

17. Comments/Questions