ESTATE PLANNING QUESTIONAIRES

ESTATE PLANNING PERSONAL DATA SHEET

(MARRIED)

Date
Home Telephone
Business Telephone

This form is extremely important. Your accuracy and completeness in responding will help me best represent you. Bring this information with you to the appointment. Please list names as they would appear on legal documents.

PERSONAL DATA

(Husband) (Wife)

Full Name                                                             Full Name
(print name as shown on your checks)                                (print name as shown on your checks)

Address

Zip

(Husband) (Wife)

Birth Date Birth Date

Social Security # Social Security #

U.S. Citizen? Yes No U.S. Citizen? Yes No

Annual Income Annual Income

REFERRAL

By whom were you referred to this office?

Name

Address

DISPOSITIVE INTENTIONS

1. Do you wish to provide primarily for your spouse and secondarily for your children?

Yes No

Do you wish to treat all of your children equally? Yes No

After your spouse's death, at what age do you want distribution to your children:

(e.g. a typical plan provides for 1/3 at age 25, 1/3 at age 30 and 1/3 at age 35)

Your choice of age:

2. Do you want to leave a specific amount of money or a percentage of your estate to your grandchildren? Yes No

If so, do you wish to treat them equally? Yes No

If so, how much?

Your choice of age:

For what purpose?

Beneficiary:

3. Do you want to leave a specific amount of money or other assets to any charity?

Yes No

If so, how much?

Name and Address of Charity

4. If you have no children, who do you wish to provide for in your Will?

EXECUTOR

Who do you wish to serve as your Executor?

First Choice

Second Choice

TRUSTEE

Who do you want to serve as your Trustee?

First Choice

Second Choice

GUARDIAN

Who do you want to act as Guardian of your minor children?

First Choice

Second Choice

LIVING WILL

Do you want your Living Will to provide for withdrawal of artificial food and fluid?

Yes No

Do you want to donate your eyes or organs? Yes No

Do you want your Health Care Representative to consult with any other person prior to acting?

Yes No

Name of proposed Health Care Agent (usually family member or friend)

Address of proposed Health Care Agent

Zip

Name of proposed Alternate Health Care Agent

Address of proposed Alternate Health Care Agent

Zip

What is the name, address and telephone number of your primary care physician?

POWER OF ATTORNEY

Name of proposed Financial Agent (usually family member or friend)

Address of proposed Financial Agent

Zip

Name of proposed Alternate Financial Agent

Address of proposed Alternate Financial Agent

Zip

MISCELLANEOUS

Do you have any other legal issues which I should be aware of? Yes No

If yes, please explain:

CHILDREN (if applicable)

CHILD'S NAME	ADDRESS WITH ZIP CODE	DATE OF BIRTH

GRANDCHILDREN (if applicable)

GRANDCHILD'S NAME	ADDRESS WITH ZIP CODE	DATE OF BIRTH

w-data.cpl

rev. 7/29/98

CLIENT ASSET INFORMATION

INTAKE FORM

MARRIED

Name of Client:

FINANCIAL SUMMARY

	LIABILITIES	ASSETS
	Husband	Wife	Joint
Bank Accounts	$_________	$_________	$_________
Real Estate (residence)	$_________	$_________	$_________
Real Estate (other)	$_________	$_________	$_________
Savings Certificates (CD's)	$_________	$_________	$_________
Stocks - Non Mutual Funds (Not Held by Broker)	$_________	$_________	$_________
Stocks - Non Mutual Funds (Held by Broker)	$_________	$_________	$_________
Bonds - Non Mutual Funds (Not Held by Broker)	$_________	$_________	$_________
Bonds - Non Mutual Funds (Held by Broker)	$_________	$_________	$_________
Mutual Funds	$_________	$_________	$_________
Note and Mortgages Receivables	$_________	$_________	$_________
Business Interests	$_________	$_________	$_________
Inheritance, etc.	$_________	$_________	$_________
Automobiles	$_________	$_________	$_________
Jewelry & Collections	$_________	$_________	$_________
Non-IRA Tax Qual. Retirement Plans	$_________	$_________	$_________
IRA's	$_________	$_________	$_________
Life Insurance	$_________	$_________	$_________
Annuities	$_________	$_________	$_________
Other Assets	$_________	$_________	$_________
TOTALS
	$_________	$_________	$_________

The undersigned hereby represents to Law Offices of Steven Feldman, and each of its attorneys that the information contained in this intake form is accurate and complete, and that the undersigned understands that the law firm and its individual lawyers will rely on this information which I am furnishing. I understand that if the information contained herein is inaccurate or incomplete, the recommendations made by the law firm may not be appropriate.

Signature of Client or Client Representative: