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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:_______________________________________
c. Birth Certificate? Yes ____________ No _____________ d. If yes, location of birth certificate: _______________ ______________________________________________________ 6. CITIZENSHIP. a. Citizen of United States? Yes ________ No __________ b. If citizen of United States, _________________________ by birth __________________________________naturalized. c. If naturalized, specify:
(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.: _____________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________
(2) If marriage was terminated by death, specify date and place of death, and status of decedent's estate, etc.: ___________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ h. Testator previously married? Yes ________ No_________ i. If testator 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.: _____________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ (2) If marriage was terminated by death, specify date and place of death, and status of decedent's
estate, etc.: ___________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ j. Has spouse executed a Will? Yes ________No ________ k. If spouse has executed a Will, was Will executed before or after marriage to testator? _______Before _________After l. Location of spouse's Will:____________________________ ______________________________________________________ m. Is testator party to any antenuptial agreement? _______Yes _______ No (1) Location of agreement:___________________________ _________________________________________________ (2) General contents of agreement: __________________
_________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ 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 property rights: _____________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ 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: _____________________________________________________ Branch: ___________________________________________________ Type of Account: __________________________________________ Title of Account: _________________________________________ Account Number:____________________________________________ Average Balance: __________________________________________ Location of Passbook: _____________________________________ 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: ___________________________________________________ Box held in name of: ______________________________________ Person entitled to enter box: _____________________________ ___________________________________________________________ Location of Key: __________________________________________ 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: _________________________________________ Company: _________________________________________________ Number of shares or principal amount: _____________________ Date acquired: ____________________________________________ Price paid or manner in which acquired: ___________________ ___________________________________________________________ Location of Certificates: _________________________________ ___________________________________________________________ 3. Type of Security: _________________________________________ Company: _________________________________________________ Number of shares or principal amount: _____________________ Date acquired: ____________________________________________ Price paid or manner in which acquired: ___________________ ___________________________________________________________ Location of Certificates: _________________________________ ___________________________________________________________ H. INSURANCE 1. LIFE INSURANCE: a. Amount: ______________________________________________ Company:______________________________________________ Policy Number: _______________________________________ Location of Property: ________________________________ ______________________________________________________ b. Amount: ______________________________________________ Company:______________________________________________ Policy Number: _______________________________________ Location of Property: ________________________________ ______________________________________________________ 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
a. _____________ _____________ _______ ______________ b. _____________ _____________ _______ ______________ c. _____________ _____________ _______ ______________ d. _____________ _____________ _______ ______________ 3. Jewelry: a. Description:__________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ b. Value:________________________________________________ ______________________________________________________ ______________________________________________________
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: ___________________________________________ __________________________________________________________ Revocable or irrevocable?_________________________________ Date established: ________________________________________ Location of trust instrument:_____________________________ __________________________________________________________ 3. Beneficiaries: ___________________________________________ __________________________________________________________ Revocable or irrevocable?_________________________________ Date established: ________________________________________ Location of trust instrument:_____________________________ __________________________________________________________
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):_____________________
__________________________________________________________ 6. Executor under Will (name): _______________________________ 7. Trustee(s) under Will, if any (names and addresses):_______ ___________________________________________________________ ___________________________________________________________ 8. Guardian, if any, for minor children (name and address): ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 9. Codicils executed by Testator?______Yes_______No 10. Dates Codicils executed: __________________________________ 11. Places Codicils executed: _________________________________ ___________________________________________________________ 12. Location of Codicils:______________________________________ ___________________________________________________________ 13. Changed circumstances (such as marriage, divorce, death, adoption or birth of children, conveyance or mortgage of devised assets, etc.) that could affect provisions of Will
or Codicil:_______________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________
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