Rainey Law, LLP – Attorneys and Counselors at Law

ESTATE PLANNING WORKSHEET

FREE NO OBLIGATION INITIAL CONSULTATION

INTRODUCTION:

Information provided is held in complete confidence and is used to analyze estate planning needs and design estate planning documents.

Completing this worksheet is not mandatory prior to the initial appointment with us, but if you can complete the worksheet prior to your appointment, more information and value will be received during the complimentary initial consultation.

During the initial appointment, we will determine your specific estate planning needs and goals. The potential cost of probate and tax which would occur with your plan will be analyzed, and methods of reducing costs and accomplishing goals will be discussed. An exact quote on fees for estate planning will be provided before you authorize completion of your estate plan.

INSTRUCTIONS:

The information requested on this worksheet may seem intrusive, but we must understand your present situation and your wishes for the future. This information enables us to plan the estate to accomplish your goals, avoid probate, and save on taxes and administrative expenses.

If you (Client #1) are Married and all information on this worksheet is identical to you and your spouse (Client #2), complete only one worksheet. If information significantly differs, consider choosing the Single version of the worksheet for each person. Unmarried couples may use the worksheet as married couples, but please select the correct marital status, as it affects our recommendations for your estate planning.

Important: For any information requested here that there isn't enough room for on the printed forms, please include that information on additional sheets of paper.

Required fields are denoted by red asterisks *

Today's Date

STATUS

Marital Status: *

CLIENT #1

First Name *

Middle Initial *

Last Name *

Date of Birth *

Social Security Number

Email Address *

Mobile Phone *

Work Phone

Home Phone

Street Address *

City *

State *

Zip *

Client #2

CLIENT #2

First Name *

Middle Initial *

Last Name *

Date of Birth *

Social Security Number

Email Address *

Mobile Phone *

Work Phone

Home Phone

Street Address *

City *

State *

Zip *

BACKGROUND

How soon would you like to complete planning? Is there a deadline, such as an upcoming trip, surgery, etc.?

What is your primary motivation for considering estate planning?

If Other above, please specify:

Do you have a will?

Client #1 *

Yes

No

Client #2 *

Yes

No

Do you have a trust?

Client #1 *

Yes

No

Client #2 *

Yes

No

Are you a U.S. citizen?

Client #1 *

Yes

No

Client #2 *

Yes

No

Were there any previous marriages?

Client #1 *

Yes

No

Client #2 *

Yes

No

Do you have any children?

Client #1 *

Yes

No

Client #2 *

Yes

No

Are any of your children not from your current marriage?

Client #1 *

Yes

No

Client #2 *

Yes

No

Do any of your children or other beneficiaries have disabilities?

Client #1 *

Yes

No

Client #2 *

Yes

No

Do you own a farm or business?

Client #1 *

Yes

No

Client #2 *

Yes

No

If yes, is there a buy-sell or stockholders agreement?

Client #1 *

Yes

No

Client #2 *

Yes

No

Do any of your children work in the business with you?

Client #1 *

Yes

No

Client #2 *

Yes

No

If yes, does the child working in the business have an ownership interest in the business?

Client #1 *

Yes

No

Client #2 *

Yes

No

Do you or any family members or potential beneficiaries have any serious health problems?

Client #1 *

Yes

No

Client #2 *

Yes

No

If yes, please describe briefly: *

Do you own a long-term care (nursing home) insurance policy?

Client #1 *

Yes

No

Client #2 *

Yes

No

Have you contracted with Client #2 with a prenuptial or community property agreement?

Have you contracted with your spouse (such as a prenuptial or community property agreement)?

Client #1 *

Yes

No

Client #2 *

Yes

No

Are you named as Trustee of any Trust, or named as an Agent under any Durable Power of Attorney (other than for your spouse or partner, if applicable)?

Client #1 *

Yes

No

Client #2 *

Yes

No

Do you hold everything jointly, or are some things separate?

All Joint (except IRA’s, Pensions, etc.)

Some Separate

NET WORTH: If you added the value of all property owned by yourself and your spouse including real estate, personal property, bank accounts, stocks, bonds, IRAs, and anything else you own except death benefits on life insurance, then what is the approximate total value of your estate?

What is the approximate total value of the estate?

What is the approximate total of your combined outstanding liabilities?

What is the approximate value of death benefits on Client #1's life insurance?

What is the approximate value of death benefits on Client #2's life insurance?

INCOME/ASSET/LIABILITY INFORMATION

Please list your income/asset/liability information in the category below. Please see the last page for more information regarding your assets.

Earned Monthly Income from Labor

Client #1

Earned Monthly Income from Labor

Client #2

Earned Monthly Income from Labor

Total

Monthly Social Security Income

Client #1

Monthly Social Security Income

Client #2

Monthly Social Security Income

Total

Monthly Pension Income

Client #1

Monthly Pension Income

Client #2

Monthly Pension Income

Total

Other Monthly Income

Client #1

Other Monthly Income

Client #2

Other Monthly Income

Total

REAL ESTATE (INCLUDING MINERAL INTERESTS IN OIL AND GAS)

Primary Personal Residence

Provide complete address here if different from Client #1 address above

Title in Which Held

Client #1 Sole

Client #2 Sole (if applicable)

Held Jointly (if applicable)

OtherOther

Current Value of Primary Personal Residence

Additional Personal Residences

Additional Personal Residence

Provide complete address here

Title in Which Held

Client #1 Sole

Client #2 Sole (if applicable)

Held Jointly (if applicable)

OtherOther

Current Value of Additional Personal Residence

Vacant Land

Provide complete address or land description

Title in Which Held

Client #1 Sole

Client #2 Sole (if applicable)

Held Jointly (if applicable)

OtherOther

Current Value

Minteral Interests

Mineral Interest in Oil or Gas

Provide complete address or land description

Title in Which Held

Client #1 Sole

Client #2 Sole (if applicable)

Held Jointly (if applicable)

OtherOther

Current Value

Other: (Include Type of Property e.g., Rentals, Vacation, Commercial, Agricultural, or Manufacturing)

Provide complete address here

Title in Which Held

Client #1 Sole

Client #2 Sole (if applicable)

Held Jointly (if applicable)

OtherOther

Current Value

LIQUID ASSETS (Include Account Number and Where Held)

Check ALL of the various types of assets that you have:

Liquid Asset Types

Total Cash on Hand

Checking Accounts

Include bank name, bank mailing address, and account number

Title in Which Held

Client #1 Sole

Client #2 Sole (if applicable)

Held Jointly (if applicable)

OtherOther

Current Value

Savings Accounts

Savings Account

Include bank name, bank mailing address, and account number

Title in Which Held

Client #1 Sole

Client #2 Sole (if applicable)

Held Jointly (if applicable)

OtherOther

Current Value

Brokerage Accounts and Publicly Traded Securities

Include bank name, bank mailing address, and account number

Title in Which Held

Client #1 Sole

Client #2 Sole (if applicable)

Held Jointly (if applicable)

OtherOther

Current Value

Unlisted Stocks/Bonds (Not Publicly Traded)

Include bank name, bank mailing address, and account number

Title in Which Held

Client #1 Sole

Client #2 Sole (if applicable)

Held Jointly (if applicable)

OtherOther

Current Value

Money Market Accounts

Include bank name, bank mailing address, and account number

Title in Which Held

Client #1 Sole

Client #2 Sole (if applicable)

Held Jointly (if applicable)

OtherOther

Current Value

Notes and Loans Receivables

Notes and Loans Receivable

Include bank name, bank mailing address, and account number

Title in Which Held

Client #1 Sole

Client #2 Sole (if applicable)

Held Jointly (if applicable)

OtherOther

Current Value

Certificates of Deposit

Certificate of Deposit

Include bank name, bank mailing address, and account number

Title in Which Held

Client #1 Sole

Client #2 Sole (if applicable)

Held Jointly (if applicable)

OtherOther

Current Value

Automobiles

Automobile

Include year, make, and model of vehicle

Title in Which Held

Client #1 Sole

Client #2 Sole (if applicable)

Held Jointly (if applicable)

OtherOther

Current Value

Other Personal Property: Automobiles, RV's, Boats, Campers, Trailers, etc

Other Personal Property: Autos, RV's, Boats, Campers, Trailers, etc.

Include year, make, and model of vehicle

Title in Which Held

Client #1 Sole

Client #2 Sole (if applicable)

Held Jointly (if applicable)

OtherOther

Current Value

Annuities

Owner

Beneficiary

Current Value

IRAs & Pension/Profit Sharing or Deferred Compensation Plans

IRAs and Pension/Profit Sharing or Deferred Compensation Plan

Include bank name, bank mailing address, and account number

Type of Plan

Traditional IRA

Roth IRA

401(k) or 403(b)

OtherOther

Current Value

Life Insurance Policies

Life Insurance Policy

Include provider name, provider address, and policy number

Title in Which Held

Client #1 Owned

Client #2 Owned (if applicable)

Employer Owned

OtherOther

Cash Value

Death Benefit

Homeowners & Motor Vehicle Insurance Company / Agent:

Homeowners & Motor Vehicle Insurance Companies / Agents:

Include provider name, provider address, and policy number

Policy Number(s):

Cash Value

CLOSELY HELD BUSINESS INTERESTS

Do you have any closely held business interests?

Client #1 *

Yes

No

Client #2 *

Yes

No

CLOSELY HELD BUSINESS INTERESTS

For each closely held business interest, such as interest in a non-publicly traded partnership, limited liability company, or corporation, etc., provide copies of your organizational documents, and provide the following information:

Percentage of Ownership:

Type of Business

Sole Proprietorship

LLC / Partnership

Corporation

Title in Which Held

Client #1 Sole

Client #2 Sole (if applicable)

Held Jointly (if applicable)

OtherOther

Fair Market Value:

Description of Product or Service:

Is there a buy/sell agreement?

Yes

No

If yes, how is it funded?

LIABILITIES

Include all mortgages, personal loans, etc.

LIABILITIES

Liability

Briefly describe liability

Client(s) Loan(s):

(Client #1, Client #2, etc.)

Amount Owed

BENEFICIARY INFORMATION

Beneficiary Number:

Full Legal Name

Date of Birth

Relationship

Address:

(write “same” if same as yours)

GIFT TAX RETURNS

Have gift tax returns ever been filed to report gifts made? (If YES, please bring copies of the returns to your appointment)

Yes

No

APPOINTMENTS

SUCCESSOR TRUSTEE. If you wish to avoid probate of your estate by executing a living trust during your lifetime, a successor trustee should be named. The person or corporate trustee selected as your personal representative is usually the same as the successor trustee. The successor trustee would manage assets if you were unable, or with a joint trust, if neither you or your spouse were able. The successor trustee would distribute assets to beneficiaries after death, or in a joint trust, should neither you or your spouse survive.

Successor Trustee Name:

Successor Trustee Complete Address:

Alternate Successor Trustee Name:

Alternate Successor Trustee Complete Address:

2nd Alternate Successor Trustee Name:

2nd Alternate Successor Trustee Complete Address:

HEALTH CARE AGENT. This individual will make medical decisions on your behalf including decisions regarding medical consents, life support issues, and nursing home admission if you cannot make these decisions yourself. Frequently, the primary agent is the spouse. It is not required to appoint the same person who is your successor trustee or personal representative as your health care agent.

Health Care Agent Name:

Health Care Agent Address:

Alternate Health Care Agent Name:

Alternate Health Care Agent Address:

DURABLE POWER OF ATTORNEY (DPOA).This individual will make financial decisions including decisions regarding securities, accounts, deed, and asset transfers on your behalf should you be unable to make these decisions yourself. Frequently, the primary agent is the spouse. It is not required for your DPOA to be the same person who is your successor trustee or personal representative. You choose below whether you intend for your DPOA to assume his power immediately upon signing, or only upon your incapacity.

DPOA Name:

DPOA Complete Address:

Alternate DPOA Name:

Alternate DPOA Complete Address:

2nd Alternate DPOA Name:

2nd Alternate DPOA Complete Address:

DPOA Immediate Power

Yes

No

DPOA Springing Power

Yes

No

PERSONAL REPRESENTATIVE. The Will should name a safety net personal representative should it become necessary to probate the estate. (Personal representative is also sometimes referred to as executor or administrator.) (Example: Client #2 as primary personal representative, with a child, relative, friend, or corporate trustee as an alternate. In second marriage situations, Client #2 as the primary personal representative may not always be appropriate.)

Personal Representative Name:

Personal Representative Complete Address:

Alternate Personal Representative Name:

Alternate Personal Representative Complete Address:

2nd Alternate Personal Representative Name:

2nd Alternate Personal Representative Complete Address:

PLAN OF DISTRIBUTION

Do you want to make charitable gifts to a person, church, or other institution? If so, please describe.

BENEFICIARIES. Briefly describe where you would want assets remaining after any gifts are distributed. (Don’t worry about tax planning or other considerations in answering this question. We’ll consider those details later if needed.)

Distribution to Beneficiaries

All to Client #2; then equally between children, and if a child didn’t survive, the deceased child’s children would take the share of the deceased child.

All to Client #2, then equally between surviving children, if any. If not, then heirs at law.

All to Client #2... (click then fill in below)

Other Distribution... (click then fill in below)

All to Client #2... (fill in here)

Other Distribution... (fill in here) *

ULTIMATE DISTRIBUTION. Provide for distributing your property if neither you, your spouse nor your children/other beneficiaries named above survive.

PLEASE COMPLETE THIS SECTION ONLY IF YOU HAVE MINOR BENEFICIARIES OR BENEFICIARIES WITH DISABILITIES

GUARDIAN. If you have minor children or a beneficiary with special needs, you may need to appoint a guardian. The guardian handles the day-to-day care of the child. Name an alternate guardian to act if your first choice cannot serve.

Guardian Name

Alternate Guardian Name

TESTAMENTARY TRUSTEE. You may need a trustee to manage assets for beneficiaries until they reach an age when you believe they should be capable of managing assets on their own. A trustee can keep the beneficiary’s money invested wisely and use it for their education, support, etc., until they reach the age specified for outright distribution of assets to them. The trustee can be a relative, friend, trust company, or other person or institution you trust to manage and distribute assets according to your wishes. The testamentary trustee can be the same person named as the guardian, or could be a different person or institution.

Testamentary Trustee Name:

Alternate Testamentary Trustee Name:

AGE OF DISTRIBUTION. If you establish a testamentary trust to allow a third party to manage assets for beneficiaries, you should decide when the beneficiaries will be mature enough to manage assets on their own. You may select from the following distributions, or speak with us about a specific plan.

Age of Distribution

All at age (Insert age below) ...

1/2 at age (Insert age below), and 1/2 at age (Insert age below) ...

1/3 at age (Insert age below), and 1/3 at age (Insert age below), and 1/3 at age (Insert age below) ...

Other (Describe below)

Specify the Age: *

Specify the Two Ages: *

Specify the Three Ages: *

Other Age of Distribution *

GENERAL QUESTIONS

NOTES AND QUESTIONS: Please note anything else which may be important in planning your estate, or questions.

Documents Needed for Completion of Estate Planning Before Signing Your Trust

While not needed now, the following documents will be necessary for us to help you fully “fund” your Trust, i.e, retitle all your assets into your Trust after you sign your Trust to avoid probate. Simply check below all that apply.

Before you sign your Estate Plan Documents, please provide us with a copy of any document or record evidencing your ownership of any of these assets. When you do provide them, also include the names of your financial institutions or insurance providers, account numbers, and mailing addresses. Copies are preferable to handwritten notes to help avoid drafting errors.

Liquid Assets Documents