A.

Background Information
Full Name:___________________________________________________________________
Marital Status:_________________ Do you have children? OYON, if yes, how many?________
Check all that apply: Provisions for a business you own:
__Minor Children (If yes, indicate the name of __I have a written Business Continuation Plan
appointed legal guardian___________________) __I wish to have my business liquidated after my
__Adopted Children death
__Children from previous Marriage Additional information, check all that apply:
__Spouse has children from previous marriage __Significant inheritance for my spouse or my
Provisions you’re considering for beneficiaries, beneficiaries
check all that apply: __I’ve named a person to act as legal
__Gifting program during my lifetime representative in the event of my incapacity or
__Additional life insurance incapacity of any of my beneficiaries (Durable
__Charitable contribution during my lifetime Power of Attorney)
__Charitable contribution after my death Name:___________________________
__I’ve named a person to manage the estate after
my death (Estate Executor)

B. Family and Other Beneficiary Information

Full Name Contact No. Date of Birth Relationship

C. Asset Inventory
I. Bank Accounts
Bank’s Name Acct. Name Account No. Amount Beneficiary

Total
II. Securities in Certificate Form
Name of Stock/Bond Stock/Bond No. No. of Shares FMV

Total
III. Insurance
Insurance Co. Contact No. Policy No. Beneficiary

Total
IV. Real Estate
Property Type Location FMV Mortgage Amt. Value (Net of Mort)

Total
V. Safe Deposit Box
Bank Contact No. Box No. Contents Executor Key Location

VI. Personal Property

Type Description Fair Market Value
Auto
Home Furnishings
Collectibles
Others
Total
VII. Unsecured Debts
Lender Contact Info. Type Outstanding Balance

Total
VIII. Debts Owed to you
Borrower Contact Info. Outstanding Balance

Total