Untitled 1

RECORD OF PERSONAL AND BUSINESS

INFORMATION FOR ESTATE PLAN

THIS DOCUMENT is a record of information concerning the personal life and business affairs of ________________________ ___________________________________________, hereinafter called testator, and was prepared by ________________________________ _____________________ from information supplied by testator on __________________________, 19 _____, in connection with preparation of the estate plan and will of testator.

A. GENERAL INFORMATION

1. NAME.

a. Full name of testator:_________________________________

b. Names, other than the name set forth above, by which

testator has been or is now known:____________________ ______________________________________________________

2. ADDRESS.

a. Present residence address:____________________________

______________________________________________________

b. Residence address other than above address:___________

______________________________________________________

c. Average length of the time spent annually at each

address:______________________________________________ ______________________________________________________

3. TELEPHONE NUMBERS.

a. Present residence:____________________________________

b. Business:_____________________________________________

4. SOCIAL SECURITY NUMBERS.

a. Testator:_____________________________________________

b. Spouse:_______________________________________________

5. BIRTH DATE.

a. Date of birth:________________________________________

b. Place of birth:_______________________________________

(1) Date of naturalization (final papers):___________ _________________________________________________

(2) Place of naturalization:_________________________ _________________________________________________

(3) Location of naturalization certificate:__________ _________________________________________________

d. If not citizen of United States, citizen of what

country?______________________________________________ ______________________________________________________

B. FAMILY INFORMATION

1. CURRENT MARITAL STATUS.

a. Married:______________________________________________

b. Divorced or marriage dissolved or annuled:____________

______________________________________________________ c. Separated:____________________________________________

d. Widowed:______________________________________________

e. Never married:________________________________________

2. IF MARRIED:

a. Date of marriage:_____________________________________

b. Location of marriage certificate: ____________________

______________________________________________________

c. Name of spouse:_______________________________________

d. Age of spouse:________________________________________

e. Address of spouse: ___________________________________

______________________________________________________

f. Spouse previously married? Yes __________ No________

g. If spouse was previously married, how was marriage

terminated: __________________________________________ ______________________________________________________ ______________________________________________________

(1) If marriage was terminated by divorce,

dissolution of marriage, or annulment, specify details, including court, date, place, property settlement agreement, etc.: _____________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________

_________________________________________________ _________________________________________________ _________________________________________________

_________________________________________________

3. IF TESTATOR DIVORCED OR MARRIAGE DISSOLVED OR ANNULED:

a. Name of state and court in which decree of divorce,

dissolution, or annulment was entered:________________ ______________________________________________________

b. Date of decree:_______________________________________

c. Location of testator's copy of decree: ______________

______________________________________________________

d. General contents of decree with respect to support and

property rights: _____________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

e. Location of any property settlement agreement or

alimony or support agreement or trust: _______________ ______________________________________________________ ______________________________________________________

f. General contents of any property settlement agreement

or alimony or support agreement or trust: ____________ ______________________________________________________ ______________________________________________________

4. IF SEPARATED:

a. Name of state and court in which separation decree was

entered: _____________________________________________ ______________________________________________________ ______________________________________________________

b. Date of decree:_______________________________________

c. Location of testator's copy of decree: _______________

______________________________________________________ ______________________________________________________

d. General contents of decree with respect to support and

e. Location of any separation agreement:

___________________________________________________

______________________________

f. General contents of any separation agreement with

respect to support and property rights: ____________________________________________________ ____________________________________________________

____________________________________________________

5. IF WIDOWED:

a. Date and place of spouse's death:__________________

___________________________________________________ ___________________________________________________ ______________________________

b. Spouse died testate;___________intestate __________

c. Has spouse's estate been administered? _____Yes

______ No

d. Name of state and court in which spouse's estate was

or is being administered: _________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

e. If estate is still being administered, general status

of administration: ________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

f. Testator's interest (as heir, legatee, devisee,

creditor, etc.) in spouse's estate:________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

6. NEXT OF KIN:

(Include children both out of wedlock, adopted children,

and children of deceased children)

BIRTH

NAME DATE ADDRESS RELATIONSHIP

__________________ __________ ____________________ _____________ __________________ __________ ____________________ _____________ __________________ __________ ____________________ _____________ __________________ __________ ____________________ _____________ __________________ __________ ____________________ _____________ __________________ __________ ____________________ _____________ __________________ __________ ____________________ _____________ __________________ __________ ____________________ _____________

C. EMPLOYMENT AND EMPLOYMENT BENEFITS

1. If Employed (including employment by closely held

corporation):

a. Name of employer:_______________________________________ b. Address:______________________________________________

c. Telephone Number:_____________________________________

d. Date employed:________________________________________

e. Location of employment agreement, if any:_____________

______________________________________________________

f. General contents of employment agreement, if any:

_____________________________________________________

_____________________________________________________ _____________________________________________________

g. Employment benefits (specify beneficiary when

appropriate):

(1) Health and accident insurance:__________________ ________________________________________________

(2) Life insurance:_________________________________ ________________________________________________

(3) Vacation:_______________________________________

(4) Pension: _______________________________________

(5) Profit sharing:_________________________________ ________________________________________________

(6) Stock options:__________________________________ ________________________________________________

(7) Other benefits:_________________________________ ________________________________________________ ________________________________________________ ________________________________________________

2. IF SELF-EMPLOYED:

a. Name of business:____________________________________

b. Address: ____________________________________________

c. Telephone Number:____________________________________

d. Nature of business:__________________________________

e. Has testator established self employment pension plan?

________Yes ________ No

3. IF RETIRED:

a. Date of retirement:___________________________________

b. Details of pension benefits other than social security

benefits: ____________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

______________________________________________________ D. MILITARY SERVICE

1. United States Military Service?________Yes__________No

If yes, branch: ___________________________________________ 2. Military Service in Foreign Countries?_______Yes______No

a. Country:______________________________________________

b. Branch of Service: ___________________________________

3. If discharged, location of discharge papers:_______________

___________________________________________________________

E. REAL PROPERTY

1. Nature of Interest:________________________________________

Description of Property:___________________________________ Holder(s) of Encumbrance(s): ______________________________ ___________________________________________________________ Location of Deed and Title Insurance Policy:_______________ ___________________________________________________________

2. Nature of Interest:________________________________________

Description of Property:___________________________________ ___________________________________________________________ Holder(s) of Encumbrance(s): _____________________________ ___________________________________________________________ Location of Deed and Title Insurance Policy:_______________ ___________________________________________________________

3. Nature of Interest:________________________________________

Description of Property: __________________________________ Holder(s) of Encumbrance(s): ______________________________ ___________________________________________________________ Location of Deed and Title Insurance Policy:_______________ ___________________________________________________________

4. Nature of Interest: _______________________________________

Description of Property: __________________________________ Holder(s) of Encumbrance(s): ______________________________ ___________________________________________________________ Location of Deed and Title Insurance Policy: ______________ ___________________________________________________________

F. SAVINGS AND LOAN, CREDIT UNION ACCOUNTS

1. Firm:______________________________________________________

Branch:____________________________________________________

Type of Account:___________________________________________ Title of Account:__________________________________________ Account Number:____________________________________________ Average Balance: __________________________________________ Location of Passbook: _____________________________________

2. Firm: _____________________________________________________

Branch: ___________________________________________________ Type of Account: __________________________________________ Title of Account: _________________________________________ Account Number:____________________________________________ Average Balance: __________________________________________ Location of Passbook: _____________________________________

3. Firm: _____________________________________________________

G. SAFE DEPOSIT BOXES

1. Box Number: _______________________________________________

Bank or Trust Company where located: ______________________ ___________________________________________________________ Branch: ___________________________________________________

Box held in name of: ______________________________________ Person entitled to enter box: _____________________________ ___________________________________________________________ Location of Key: __________________________________________

2. Box Number: _______________________________________________

Bank or Trust Company where located: ______________________ ___________________________________________________________ Branch: ___________________________________________________

G.(a) SECURITIES

1. Type of Security: _________________________________________

Company: _________________________________________________ Number of shares or principal amount: _____________________ Date acquired: ____________________________________________ Price paid or manner in which acquired: ___________________ ___________________________________________________________ Location of Certificates: _________________________________ ___________________________________________________________

2. Type of Security: _________________________________________

3. Type of Security: _________________________________________

H. INSURANCE

1. LIFE INSURANCE:

a. Amount: ______________________________________________

Company:______________________________________________ Policy Number: _______________________________________ Location of Property: ________________________________ ______________________________________________________

b. Amount: ______________________________________________

c. Amount: ______________________________________________

Company:______________________________________________ Policy Number: _______________________________________

Location of Property: ________________________________ ______________________________________________________

2. OTHER INSURANCE:

a. Kind:_________________________________________________

Amount: ____________________________________________

Company: _____________________________________________ Policy Number:________________________________________ Location of Property:_________________________________ ______________________________________________________

b. Kind:_________________________________________________

Amount: ____________________________________________

Company: ____________________________________________

Policy Number:________________________________________ Location of Property: ________________________________ ______________________________________________________

c. Kind:_________________________________________________

Amount: ____________________________________________

Company: ____________________________________________

Policy Number:________________________________________ Location of Property: ________________________________ ______________________________________________________

I. PERSONAL PROPERTY

1. Furniture and Furnishings; Household Goods and Appliances:

________________________ ______________________________

2. Motor Vehicles; Boats; Aircraft:

Make Model Year Location

c. Location:____________________________________________

______________________________________________________ ______________________________________________________

4.STAMP AND COIN COLLECTION; PAINTINGS AND OTHER ART

OBJECTS:

a. Description:__________________________________________

______________________________________________________ ______________________________________________________

Value:________________________________________________ ______________________________________________________ ______________________________________________________

Location: ____________________________________________ ______________________________________________________ ______________________________________________________

b. Description:__________________________________________

______________________________________________________ ______________________________________________________

Value:________________________________________________ ______________________________________________________ ______________________________________________________

Location: ____________________________________________ ______________________________________________________ ______________________________________________________

c. Description:__________________________________________

______________________________________________________ ______________________________________________________

Value:________________________________________________ ______________________________________________________ ______________________________________________________

Location: ____________________________________________ ______________________________________________________ ______________________________________________________

5. MISCELLANEOUS PERSONAL PROPERTY:

a. Description:__________________________________________

______________________________________________________ ______________________________________________________

Value:________________________________________________ ______________________________________________________ ______________________________________________________

Location:____________________________________________ ______________________________________________________ ______________________________________________________

b. Description:__________________________________________

______________________________________________________ ______________________________________________________

Value:________________________________________________

______________________________________________________ ______________________________________________________

Location: ____________________________________________ ______________________________________________________ ______________________________________________________

c. Description:__________________________________________

______________________________________________________ ______________________________________________________

Value:________________________________________________ ______________________________________________________ ______________________________________________________

Location: ____________________________________________ ______________________________________________________ ______________________________________________________

J. BUSINESS INTERESTS OF TESTATOR

1. a. Name of Business:_____________________________________

______________________________________________________

b. Nature of Business: __________________________________

______________________________________________________ ______________________________________________________ ______________________________________________________

c. Form of Organization:_________________________________

______________________________________________________

d. Net Worth:____________________________________________

e. Testator's Interest:__________________________________

______________________________________________________

f. Testator's Position: _________________________________

______________________________________________________

K. PATENTS, COPYRIGHTS, FRANCHISES, ETC.

a. Type: _______________________________________________

_____________________________________________________

b. Nature of Testator's Interest: ______________________

_____________________________________________________

c. Date of Acquisition: ________________________________

_____________________________________________________

d. Value: ______________________________________________

_____________________________________________________ _____________________________________________________

L. OBLIGATIONS OWED TO TESTATOR

1. a. Description of Debt: ________________________________

_____________________________________________________ Evidenced by: ______________________________________

____________________________________________________

Balance due: ________________________________________ _____________________________________________________

Name of Debtor: _____________________________________ _____________________________________________________

Address of Debtor:___________________________________

_____________________________________________________

b. Description of Debt: ________________________________

_____________________________________________________ Evidenced by: ______________________________________

____________________________________________________

Balance due: ________________________________________ _____________________________________________________

Name of Debtor: _____________________________________ _____________________________________________________

Address of Debtor:___________________________________

_____________________________________________________

c. Description of Debt: ________________________________

_____________________________________________________ Evidenced by: ______________________________________

____________________________________________________

Balance due: ________________________________________ _____________________________________________________

Name of Debtor: _____________________________________ _____________________________________________________

Address of Debtor:___________________________________

_____________________________________________________

M. TESTATOR'S INTEREST IN TRUSTS AND ESTATES

1. Testator Beneficiary of Trust?_______Yes ______No

a. Location of trust instrument:________________________

_____________________________________________________

b. General Contents of trust instrument: _______________

_____________________________________________________ _____________________________________________________

2. Does Testator expect inheritance from persons other than

deceased spouse? _________Yes_________No

a. Estate(s) of_________________________________________

_____________________________________________________ _____________________________________________________

b. Name of state and court of administration: _________

_____________________________________________________ _____________________________________________________

c. General analysis of status and rights:_______________

_____________________________________________________ _____________________________________________________

N. TAX RETURNS

1. Location of returns:______________________________________

_________________________________________________________

2. Location of supporting documents:_________________________

__________________________________________________________

3. Returns prepared by: (name and address)___________________

__________________________________________________________

O. PENDING LITIGATION

1. Testator, Plaintiff or Defendant? ________________________

__________________________________________________________

2. State and Court: _________________________________________

__________________________________________________________

3. Nature of dispute:________________________________________

__________________________________________________________

4. Amount in controversy: ___________________________________

__________________________________________________________

5. Current status of litigation: ____________________________

__________________________________________________________

6. Testator represented by: _________________________________

__________________________________________________________

P. OBLIGATIONS OWED BY TESTATOR

1. Nature of obligation: ____________________________________

Evidenced by:_____________________________________________

Creditor:_________________________________________________

Address:__________________________________________________

Amount:___________________________________________________

2. Nature of obligation: ____________________________________

Evidenced by:_____________________________________________

Creditor:_________________________________________________

Address:__________________________________________________

Amount:___________________________________________________

3. Nature of obligation: ____________________________________

Evidenced by:_____________________________________________

Creditor:_________________________________________________

Address:__________________________________________________

Amount:___________________________________________________

Q. INTERVIVOS TRUST ESTABLISHED BY TESTATOR

1. Beneficiaries: ___________________________________________

__________________________________________________________

Revocable or irrevocable?_________________________________ Date established: ________________________________________ Location of trust instrument:_____________________________ __________________________________________________________

2. Beneficiaries: ___________________________________________

__________________________________________________________

3. Beneficiaries: ___________________________________________

__________________________________________________________

R. GIFTS, TRANSFERS, AND ADVANCEMENTS MADE BY TESTATOR

1. Donee:____________________________________________________

Type of gift:_____________________________________________ Value: ___________________________________________________ Date: ____________________________________________________

2. Donee:____________________________________________________

Type of gift:_____________________________________________ Value: ___________________________________________________ Date: ____________________________________________________

3. Donee:____________________________________________________

Type of gift:_____________________________________________ Value: ___________________________________________________ Date: ____________________________________________________

4. Gift tax returns filed:__________Yes_________ No

5. If yes, prepared by: _____________________________________

__________________________________________________________

S. FIDUCIARY DUTIES AND POWERS OF APPOINTMENT OF TESTATOR

1. FIDUCIARY CAPACITIES OF TRUSTEE:__________________________

__________________________________________________________

a. Manner of creation: _________________________________

_____________________________________________________ _____________________________________________________

b. Location of instrument under which fiduciary

capacities created:__________________________________ _____________________________________________________

c. General description of status: ______________________

_____________________________________________________

2. POWERS OF APPOINTMENT: ___________________________________

__________________________________________________________

a. Instrument under which power created: _______________

_____________________________________________________

b. Location of instrument:______________________________

c. General contents of instrument:______________________

_____________________________________________________

T. WILLS AND CODICILS

1. Will executed by Testator?__________Yes_________ No

2. Date Will executed: ______________________________________

3. Place Will executed: _____________________________________

4. Location of Will (address): ______________________________

__________________________________________________________

5. Attorney who prepared Will (address):_____________________

or Codicil:_______________________________________________ __________________________________________________________ __________________________________________________________

__________________________________________________________ __________________________________________________________