Estate Planning Worksheet

Using this worksheet will assist us in getting to know you prior to our consultation and designing a plan that meets your needs and goals. All information provided is strictly confidential.

Part I: Personal Information
Part II: Important Questions
Part III: Your Estate- Assets & Debts
Part IV: Estate Plan Design Information- Decision Makers
Part V: Estate Plan Design Information- Distribution of Property

Not every section will apply to you and your situation- you can leave those areas blank. If you are unsure of an answer, or would rather discuss the issue in person, feel free to leave the section blank. If possible, please submit the completed worksheet (along with any supporting documents) to our office 48 hours prior to your appointment. Should you have any questions, please contact Danielle Browne via email at danielle@thebrownefirm.com.

Thank you and we look forward to meeting with you soon!

Part I: Personal Information

^•Client’s Legal First Name

Client’s Legal Middle Name

Client’s Legal Last Name

(name most often used to title property and accounts)

Also known as

(other names used to title property and accounts)

Prefer to be called

Birth date

SS#

US Citizen? (If Yes, check box)

Home Address

City

State

Zipcode

Cell Phone

Home Phone

County of Residence

Employer

Position

E-mail Address

It is okay to communicate with me via my E-mail address.

Date of Marriage/Domestic Partnership Filing:

Partner

^•Partner's Legal First name

Partner's Legal Middle name

^•Partner's Legal Last name

Also Known As (other names used to title and accounts)

U.S Citizen?

Prefer to be called

Birthdate

SS#

Address (Primary) - Street

Address (Primary) - Street2

County of Residence

Address (Primary) - City

Address (Primary) - State

Address (Primary) - Zipcode

Employer

Position

Email (Primary)

It is okay to communicate with me via my E-mail address.

Phone (Primary)

We both need estate planning documents.

Your Children/Dependents

(please use full legal name)

Do you have any children and/or dependents?

Child/Dependent

^•First name

Last name

Birthdate

Relationship

Advisors

Financial Advisor Name

Telephone

Accountant Name

Telephone

Life Insurance Agent

Telephone

Insurance Policies:

(please list company & policy limits if known)

Homeowners/Renters

Auto

Business/E&O/Malpr.

Long-Term Care

Other

Umbrella

Part II: Important Family Questions

(Please check for "Yes", leave blank for "No")

Have you (or your Partner) ever completed a will, trust, and/or estate planning?

Please upload copies of these documents:

Drop files here, or click to select files to upload.

Are you (or your Partner) receiving Social Security, disability, or other governmental benefits?

Describe:

Are you (or your Partner) making payments pursuant to a divorce or property settlement order?

Please upload a copies of these documents:

Drop files here, or click to select files to upload.

Have you and your Partner signed a pre- or post-marriage/domestic partnership agreement/contract?

Please upload a copy of this document:

Drop files here, or click to select files to upload.

Have you (or your Partner) been widowed?

If a federal estate tax return or a state death tax return was filed, please upload a copy:

Drop files here, or click to select files to upload.

Have you (or your Partner) ever filed federal or state gift tax returns?

Please upload copies of these returns:

Drop files here, or click to select files to upload.

Do you support any charitable organizations now that you wish to make provisions for at the time of your death?

Please explain:

Are there any other charitable organizations you wish to make provisions for at the time of your death?

Please explain:

Have you lived in any of the following states while married to each other? Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, or Wisconsin

Are you (or your Partner) currently the beneficiary of anyone else’s trust?

Please explain:

Do any of your children/dependents have special educational, medical, or physical needs?

Do any of your children receive governmental support or benefits?

Do you provide primary or other major financial support to adult children or others?

Are you currently involved in a bankruptcy proceeding?

Please Explain:

Are you currently involved in a lawsuit (plaintiff/defendant)?

Additional Information

Your Concerns

Please rate the following as to how important they are to you:

(H high concern, S some concern, L low concern, N/A no concern or not applicable)

Description

Client's Level of Concern

Partner's Level of Concern

Desire to get affairs in order and create a comprehensive plan to manage affairs in case of death or disability.

Client's Level of Concern

Partner's Level of Concern

Providing for and protecting a Partner.

Client's Level of Concern

Partner's Level of Concern

Providing for and protecting children.

Client's Level of Concern

Partner's Level of Concern

Providing for and protecting grandchildren.

Client's Level of Concern

Partner's Level of Concern

Disinheriting a family member.

Client's Level of Concern

Parnter's Level of Concern

Preserving the privacy of affairs in case of disability or at time of death from business competitors, predators, dishonest persons and curiosity seekers.

Client's Level of Concern

Partner's Level of Concern

Plan for the transfer and survival of a business if I am unable to work

Client's Level of Concern

Partner's Level of Concern

Avoiding or reducing your estate taxes.

Client's Level of Concern

Partner's Level of Concern

Avoiding probate at time of death.

Client's Level of Concern

Partner's Level of Concern

Avoiding a guardianship (“living probate”) in case of a disability.

Client's Level of Concern

Partner's Level of Concern

Avoiding will contests or other disputes upon death.

Client's Level of Concern

Partner's Level of Concern

Protecting assets from lawsuits or creditors.

Client's Level of Concern

Partner's Level of Concern

Maintaining/bolstering my privacy (as it may relate to personal and/or business assets)

Client's Level of Concern

Partner's Level of Concern

Plan for a child with disabilities or special needs, such as medical or learning disabilities.

Client's Level of Concern

Partner's Level of Concern

Protecting children’s inheritance from the possibility of failed marriages.

Client's Level of Concern

Partner's Level of Concern

Protect children’s inheritance in the event my surviving Partner gets remarried.

Client's Level of Concern

Partner's Level of Concern

Provide that your death shall not be unnecessarily prolonged by artificial means or measures.

Client's Level of Concern

Partner's Level of Concern

Updating/making changes to an existing business.

Client's Level of Concern

Partner's Level of Concern

Integrating an existing business into my overall estate plan.

Client's Level of Concern

Partner's Level of Concern

Other Concerns (Please list below):

Part III: Your Estate - Assets & Debts

Instructions for completing the Property Information checklist:

General Headings: This Property Information checklist helps you list all the property you own and what it is worth. If you do not own property under a particular heading, just leave that section blank. Under certain headings, you may own more property than can be listed on this checklist. If so, include it at the bottom of this section under additonal property. attach extra sheets of paper to list your additional property.

Type: Immediately after the heading for each kind of property is a brief explanation of what property you should list under that heading.

Owner of Property: How you own your property is extremely important for purposes of properly designing and implementing your estate plan. For each property, please indicate how the property is titled (i.e. individual, joint (include joint owner name) trust, LLC, corporation, other).

ASSETS

Real Property

TYPE: Any interest in real estate including your family residence, vacation home, timeshare, vacant land, etc.

General Description and/or Address (indicate if primary residence)

Owner

Market Value

Loan Balance

Add Property?

General Description and/or Address (indicate if primary residence)

Owner

Market Value

Loan Balance

Add Property?

General Description and/or Address (indicate if primary residence)

Owner

Market Value

Loan Balance

Total

Furniture and Personal Effects

TYPE: List separately only major personal effects such as jewelry, collections, antiques, furs, and all other valuable non-business personal property (indicate type below and give a lump sum value for miscellaneous, less valuable items.).

Miscellaneous Furniture and Household Effects (Total)

Owner

Market Value

Add another?

Type or Description:

Owner

Market Value

Add another?

Type or Description:

Owner

Market Value

Add another?

Type or Description:

Owner

Market Value

Add another?

Type or Description:

Owner

Market Value

Total

Automobiles, Boats, and RVs

TYPE: For each motor vehicle, boat, RV, etc. please list the following: description, how titled, market value and loans (if applicable):

Bank Accounts

TYPE: Checking Account “CA”, Savings Account “SA”, Certificates of Deposit “CD”, Money Market “MM” (indicate type below). Do not include IRAs or 401(k)s here

Note: If Account is in your name (or your partner’s name) for the benefit of a minor, please specify and give minor’s name.

Name of Institution

Type

Owner

Amount

Add Bank Account?

Name of Institution

Type

Owner

Amount

Add Bank Account?

Name of Institution

Type

Owner

Amount

Add Bank Account?

Name of Institution

Type

Owner

Amount

Add Bank Account?

Name of Institution

Type

Owner

Amount

Add Bank Account?

Name of Institution

Type

Owner

Amount

Total of All Bank Accounts:

Stocks/Bonds, Mutual Funds, Etc.

TYPE: List any and all stocks and bonds you own. If held in a brokerage account, lump them together under each account. (indicate type below)

Stocks, Bonds or Investment Account Institution

Type

Owner

Amount

Add Stocks and Bonds?

Stocks, Bonds or Investment Account Institution

Type

Owner

Amount

Add Stocks and Bonds?

Stocks, Bonds or Investment Account Institution

Type

Owner

Amount

Add Stocks and Bonds?

Stocks, Bonds or Investment Account Institution

Type

Owner

Amount

Add Stocks and Bonds?

Stocks, Bonds or Investment Account Institution

Type

Owner

Amount

Add Stocks and Bonds?

Stocks, Bonds or Investment Account Institution

Type

Owner

Amount

Total

Life Insurance Policies and Annuities

TYPE: Term, whole life, split dollar, group life, annuity.

Institution

Type

Face Amount (death benefit)

Death Beneficiaries (Primary/Contingent)

Add Another Policy?

Institution

Type

Face Amount (Death Benefit)

Death Beneficiaries (Primary/Contingent)

Retirement Plans

TYPE: Pension (P), Profit Sharing (PS), H.R. 10, IRA, SEP, 401k, 403b.

Institution

Type

Approx. Value

Death Beneficiaries (Primary/Contingent)

Add Another Retirement Plan?

Institution

Type

Approx. Value

Death Beneficiaries (Primary/Contingent)

Business Interests

TYPE: General and Limited Partnerships, Sole Proprietorships, privately-owned corporations, professional corporations, oil interests, farm, and ranch interests. ADDITIONAL INFORMATION: Give a description of the interests, who has the interest, your ownership in the interests, and the estimated value of the interests.

Total

Money Owed To You

TYPE: Mortgages or promissory notes payable to you, or other moneys owed to you.

Name of Debtor

Date of Note

Maturity Date

Owed to

Current Balance

Add another?

Name of Debtor

Date of Note

Maturity Date

Owed to

Current Balance

Add another?

Name of Debtor

Date of Note

Maturity Date

Owed to

Current Balance

Add another?

Name of Debtor

Date of Note

Maturity Date

Owed to

Current Balance

Total

Anticipated Inheritance, Gift, or Lawsuit Judgment

TYPE: Gifts or inheritances that you expect to receive at some time in the future; or moneys that you anticipate receiving through a judgment in a lawsuit. Describe in appropriate detail.

Description

Total estimated value

Other Assets

TYPE: Other property is any property that you have that does not fit into any listed category.

Type

Owner

Value

Add Asset?

Type

Owner

Value

Add Asset?

Type

Owner

Value

Add Asset?

Type

Owner

Value

Add Asset?

Type

Owner

Value

Total

DEBTS

Please include information related to debt, including:

Debtor/guarantor (i.e. individual, joint (include joint owner name), trust, LLC, corporation, other)
Institution (i.e. Bank of America, Charles Schwab)
Approximate Amount Owed & Terms
Debt Associated With ______ (i.e. Mortgage on Primary Residence)
Joint Property values enter 1/2 in client’s column and 1/2 in Partner's column. If Joint Owner is not spouse, only include Client's portion

Mortgages

Client

Partner

Approx. Balance

Interest Rate

Terms

Associated with Primary Residence?

Add Another Mortgage?

Client

Partner

Approx. Balance

Interest Rate

Terms

Associated with Primary Residence?

Credit Card(s)

Client

Partner

List Institutions

Approx. Balance

Student Loans

Client

Partner

List Institutions

Approx. Balance

Personal Loans

Client

Partner

Approx. Balance

IRS/State Taxes Owed

(back taxes & payment plans only)

Client

Partner

Approx. Balance

Other Debt(s)

Client

Partner

Approx. Balance

Part IV: Estate Plan Design Information - Decision Makers

This section helps us to design your Estate Plan. Here you will list your choices for person(s) you would like to serve in your place, should you be incapacitated or you pass away. Please list in order of succession. If decision makers are to serve jointly, please indicate. If you do not have your decision maker's contact information, you can provide to us at a later date. If you are undecided as to your decision makers, or want to discuss further during your consultation, please leave blank. Note: Most couples forming joint trust choose the same Successor Trustees, however you may choose separate designations. who would you want to make decisions for you with regard to your property and assets owned by you

If there is a person serving in more than one role, you can just include their first and last name after filling out their complete contact information the first time.

Initial Trustee: Usually the Maker will be the Trustee of his or her own trust. Often, both partners, jointly. Allows you to continue to jointly control your assets as before.

Is the initial trustee also the trust maker?

Initial Trustee

^•First name

Last name

Email (Primary)

Phone (Primary)

Birthdate

Address (Primary) - Street

Address (Primary) - Street2

Address (Primary) - Country

Address (Primary) - City

Address (Primary) - State

Address (Primary) - Zipcode

Relationship to You

I want one person to handle my assets during any periods of incapacity/disability and another person to handle my assets upon my death upon my death.

Successor Trustee: If you were unable to make decisions for yourself due to incapacity/disability, or upon death (and your Partner was not available), who would you want to make decisions for you with regard to your property and assets owned by the trust?

Successor Trustee

^•First name

Last name

Email (Primary)

Phone (Primary)

Birthdate

Address (Primary) - Street

Address (Primary) - Street2

Address (Primary) - City

Address (Primary) - State

Address (Primary) - Zipcode

Address (Primary) - Country

Relationship to you

Citizenship

DISABILITY TRUSTEE: If you were unable to make decisions for yourself, who would you want to make decisions for you with regard to your property and assets?

Disability Trustee

^•First name

Last name

Phone (Primary)

Birthdate

Email (Primary)

Address (Primary) - Street

Address (Primary) - Street2

Address (Primary) - City

Address (Primary) - State

Address (Primary) - Zipcode

Address (Primary) - Country

Relationship to You

Citizenship

DEATH TRUSTEE: After your death, who do you want carrying out your instructions, for distribution to and, if desired, management of property for your beneficiaries?

Death Trustee

^•First name

Last name

Phone (Primary)

Email (Primary)

Birthdate

Address (Primary) - Street

Address (Primary) - Street2

Address (Primary) - City

Address (Primary) - State

Address (Primary) - Zipcode

Address (Primary) - Country

Relationship to you

Citizenship

GUARDIANS FOR MINOR CHILDREN

PERMANENT GUARDIAN FOR MINOR CHILDREN: If you have any children under the age of 18, list in order of preference, who you wish to be custodial/physical, guardian of the children (if both parents/legal guardians were not available).

Permanent Guardian for Minor Children

^•First name

Last name

Email (Primary)

Phone (Primary)

Birthdate

Address (Primary) - Street

Address (Primary) - Street2

Address (Primary) - City

Address (Primary) - State

Address (Primary) - Zipcode

Address (Primary) - Country

Relationship to you

Citizenship

Does your permanent guardian live out of town?

TEMPORARY GUARDIAN FOR MINOR CHILDREN: Should your guardians listed above live out of town, please list any person(s) who would allow to have temporary guardianship (i.e. in an emergency) over your children.

Temporary Guardian for Minor Children

^•First name

Last name

Email (Primary)

Phone (Primary)

Birthdate

Address (Primary) - Street

Address (Primary) - Street2

Address (Primary) - City

Address (Primary) - State

Address (Primary) - Zipcode

Address (Primary) - Country

Relationship to you

Citizenship

POWER OF ATTORNEY: If you were unable to make financial decisions for yourself, who would you want to make those decisions for you?

Power of Attorney

Last name

^•First name

Email (Primary)

Phone (Primary)

Birthdate

Address (Primary) - Street

Address (Primary) - Street2

Address (Primary) - City

Address (Primary) - State

Address (Primary) - Zipcode

Address (Primary) - Country

Relationship to you

Citizenship

Specific Instructions, Restrictions or Guidelines for POA (if any)

Do you want to authorize your Power of Attorney to make gifts on your behalf during any period of time you are incapacitated?

Gifting Power Details:

LIVING WILL:

Do you want to provide that the moment of your death not be unnecessarily prolonged by artificial means or measures?

Do you want to provide that your organs and tissues should be made available for transplant purposes?

HEALTH CARE: If you were unable to make health care decisions for yourself, who would you want to make decisions for you with regard to your medical treatment?

Health Care Proxy

^•First name

Last name

Email (Primary)

Phone (Primary)

Birthdate

Address (Primary) - Street

Address (Primary) - Street2

Address (Primary) - City

Address (Primary) - State

Address (Primary) - Zipcode

Address (Primary) - Country

Relationship to You

Citizenship

Specific Instructions or Guidelines Health Care Proxy (if any)

Do you want to provide that upon certification by 2 physicians of need for psychological or substance treatment, Agent may arrange for voluntary admission?

Do you want to authorize your Health Care Proxy to take whatever steps are necessary to keep you in a personal residence rather than nursing home?

In making distributions during any period of time the client is incapacitated, the successor Trustee shall give primary consideration to:

Your needs and then the needs of others dependent upon you.

Your needs and the needs of others dependent upon you equally.

Other

Please describe:

Burial

Cremation

Burial

Other Wishes

Please describe

V. Estate Plan Design Information: Distributions of Property

In this section, please list your beneficiaries, i.e. the person(s)/charities you want to inherit your estate after you pass away. There are many options for distribution to the beneficiaries (outright, structured/staggered trusts, special needs trusts, asset protection trusts, etc.) which we can discuss during your consultation.

WHO gets my stuff?

SPECIFIC GIFTS: List any specific gifts of real property or cash gifts (i.e. “My house” or “$10,000”) that you wish to make to either individuals or charities. Personal Property is handled separately (i.e. do not list items of a personal nature, like jewelry or art).