Personal and Financial Information Form *** All information contained in this form is confidential and protected by attorney-client privilege. ***

I AM FILLING THIS FORM OUT FOR: □ MYSELF (and Spouse/Partner) □ SOMEONE ELSE (Parent/Relative)

If you are filling this form out on behalf of someone else, what is your name and your relationship to them: Your Name: _______________________________________________ Relationship: __________________________ Home Phone: ____________________ Cell: ____________________ Email: _______________________________

CLIENT INFORMATION

Client Spouse/Partner (if applicable)

Legal Name

Name Used to Sign

Street Address

City, State, Zip

Date of Birth

Date of Marriage

Home Phone

Cell Phone

Work Phone

Email Address Employment Status □ Retired

□ Employed□ Retired□ Employed

Citizenship □ US citizen □ Resident Alien□ Naturalized citizen

□ US citizen □ Resident Alien□ Naturalized citizen

Which number(s) would you prefer to be contacted at? □ Home □ Cell □ Work What time is best? ______________

Referred to us by: Name: Firm Name (if applicable):

Do you or your spouse have a financial advisor and/or accountant? □ Yes □ No □ Don’t Know

• Financial Advisor: Firm: Phone: • Accountant: Firm: Phone: • Who is your primary physician? Phone:

Existing Estate Planning: You Spouse □ NA Date Document Executed

Will □ Yes □ No □ Yes □ No Date:____________________ Trust □ Yes □ No □ Yes □ No Date:____________________ Power of Attorney □ Yes □ No □ Yes □ No Date:____________________ Health Care Directive □ Yes □ No □ Yes □ No Date:____________________ Living Will □ Yes □ No □ Yes □ No Date:____________________ Long-Term Care Insurance □ Yes □ No □ Yes □ No Daily benefit:_____________

Your health status plays an important role in the designing of an estate plan best suited for you and your loved ones.

Client – current health status: □ Good □ Concern □ Problem Specific concern/problem: _______________________________________________________________________________ Spouse/Partner – current health status: □ Good □ Concern □ Problem Specific concern/problem: _______________________________________________________________________________

CHILDREN and/or OTHER FAMILY MEMBERS

Child’s Full Legal Name: Also Known As: Address: Phone: Date of Birth: Relationship: Son (Joint) Son (of husband) Son (of wife)

Daughter (Joint) Daughter (of husband) Daughter (of wife) Other ______________ Check if this child is to be disinherited.

Check if this child’s descendants are also to be disinherited

Child’s Full Legal Name: Also Known As: Address: Phone: Date of Birth: Relationship: Son (Joint) Son (of husband) Son (of wife)

Daughter (Joint) Daughter (of husband) Daughter (of wife) Other ______________ Check if this child is to be disinherited.

Check if this child’s descendants are also to be disinherited

Child’s Full Legal Name: Also Known As: Address: Phone: Date of Birth: Relationship: Son (Joint) Son (of husband) Son (of wife)

Daughter (Joint) Daughter (of husband) Daughter (of wife) Other ______________ Check if this child is to be disinherited.

Check if this child’s descendants are also to be disinherited

Child’s Full Legal Name: Also Known As: Address: Phone: Date of Birth: Relationship: Son (Joint) Son (of husband) Son (of wife)

Daughter (Joint) Daughter (of husband) Daughter (of wife) Other ______________ Check if this child is to be disinherited.

Check if this child’s descendants are also to be disinherited

***IF YOU HAVE MORE CHILDREN, LIST THEIR NAMES AND INFORMATION ON THE LAST PAGE***

If you have minor children and you and your spouse or ex-spouse are deceased, who would you like to care for your children and be their LEGAL GUARDIAN?

1st Choice ________________________________

2nd Choice ________________________________

ESTATE PLANNING INFORMATION IF YOU ARE UNABLE TO MAKE MEDICAL DECISIONS, WHO WOULD YOU WANT TO MAKE THEM FOR YOU?

Client, Choice 1: __________________________ Spouse/Partner, Choice 1: __________________________

Relationship: _______________________ Relationship: _________________________

Client, Choice 2: __________________________ Spouse/Partner, Choice 2: __________________________

Relationship: _______________________ Relationship: _________________________

Client, Choice 3: __________________________ Spouse/Partner, Choice 3: __________________________

Relationship: _______________________ Relationship: _________________________

IF YOU ARE UNABLE TO MAKE FINANCIAL DECISIONS, WHO WOULD YOU WANT TO MAKE THEM FOR YOU?

Client, Choice 1: __________________________ Spouse/Partner, Choice 1: __________________________

Relationship: _______________________ Relationship: _________________________

Client, Choice 2: __________________________ Spouse/Partner, Choice 2: __________________________

Relationship: _______________________ Relationship: _________________________

Client, Choice 3: __________________________ Spouse/Partner, Choice 3: __________________________

Relationship: _______________________ Relationship: _________________________

ASSUMING YOU (AND SPOUSE/PARTNER) WOULD BE THE INITIAL TRUSTEE(S) OF YOUR TRUST, WHO WOULD YOU LIKE TO SUCCEED YOU IF YOU ARE DISABLED OR DECEASED?

First Choice: __________________________________________________ Relationship: _________________ Second Choice: ________________________________________________Relationship: _________________

BENEFICIARIES:

Is there any person you want to disinherit? □ Yes □ No If so, please list name(s):_____________________________ ________________________________________________________________________________________________

Any Charities, Churches or Non-Profits you want to give to? □ Yes □ No If so, please list on the chart below.

If you and your spouse are deceased, would you like everything (except items of personal property) to go equally to your children? □ Yes □ No If no, please list distribution amounts on the chart below.

Beneficiary Name Amount or % Date/Age of Inheritance

Contact Information

Financial Information Sheet** It is very important you indicate in each category ownership and dollar amount separately, as well as total value.**

MONTHLY INCOME:

SOURCE YOU SPOUSE JOINT TOTAL

Wages $ $ $ $

Pension $ $ $ $

Social Security $ $ $ $

Investments $ $ $ $

Other $ $ $ $

Total Value $ $ $ $

ASSET INFORMATION AS OF __________________ (date) - Please provide total amount for each type of asset and who owns.

TYPE OF ASSET YOU SPOUSE JOINT TOTAL

Cash, Checking, Savings, CD=s, Money Market & Cash Management Accounts $ $ $ $

Investment/Broker-held Accounts (not including cash) and Mutual Fund Accounts $ $ $ $

Retirement Accounts: IRA, 401K, 403B, SEP, etc. $ $ $ $

Life Insurance: death benefit and cash value D.B. $C.V. $

D.B. $C.V. $

D.B. $C.V. $

D.B. $C.V. $

Stocks: you hold (not in brokerage accounts) $ $ $ $

Bonds: bonds you hold (not in brokerage accounts) $ $ $ $

Annuities: $ = original amount invested date=month/year purchased CV=current value

$ ______ date ____ CV _____________

$ ______ date ____ CV _____________

$ ______ date ____ CV _____________

$ ______ date ____ CV _____________

Real estate: residence (per tax bill) $ $ $ $

Real estate: other $ $ $ $

Vehicles: automobile, motorcycle, boats, snowmobiles, etc. $ $ $ $

Total Value $ $ $ $ Over Please º

OTHER ASSETS NOT LISTED:

TYPE YOU SPOUSE JOINT TOTAL

$ $ $ $

$ $ $ $

Total Value $ $ $ $

LIABILITIES:

TYPE YOU SPOUSE JOINT TOTAL

Mortgage $ $ $ $

Loans Payable $ $ $ $

Other $ $ $ $

Total Value $ $ $ $

BUSINESS INTEREST:

TYPE YOU SPOUSE JOINT TOTAL

Farm $ $ $ $

Partnership or LLC Interest $ $ $ $

Corporation □-Corp? $ $ $ $

Other: $ $ $ $

Total Value $ $ $ $

Notes/Comments:

MONTHLY LIVING EXPENSES CLIENT/JOINT SPOUSE TOTAL

Medical (Complete detail on back of form) $ $ $ Non-Medical (How much you spend on other expenses monthly) $ $ $

MONTHLY MEDICAL EXPENSES (Complete all that apply)

MONTHLY EXPENSES:

Client’s Expenses

Spouse’s Expenses

TOTAL

Assisted Living Costs Nursing Home Costs In Home Care Day Program Medications Co-Pays for Doctor Medicare A Medicare Supplement Medicare B Medicare D Hygienic Supplies Other

TOTAL $______________

VA AID & ATTENDANCE ELIGIBILITY INFORMATION: 1. Are either you or your spouse a veteran?

Yes, I (or my spouse) am/is a veteran Yes, both of us are veterans No

2. Are you the surviving spouse of a veteran? Yes No Have you remarried since your prior spouse’s death? Yes No

3. Did the veteran serve for at least 90 days active duty and one day during war time?(World War II: 12/7/1941 to 12/31/1946; Korean Conflict: 6/27/1950 to 1/31/1955; Vietnam Era: 8/5/1964 to 5/7/1975 (2/28/1961 if they physically served in Vietnam); or Gulf Wars: 8/2/1990- TBD)

No Dates of service: _ Yes _______________________________

4. Did the veteran receive discharge under honorable, general, or medical discharge? Yes No

5. Is the Veteran/Spouse under 65 and unable to work due to disability? Yes No

6. Is the Veteran/Spouse over the age of 65? Yes No

NOTES/INSTRUCTIONS: Please simply fill out the form to the best of your ability. If you have any difficulties or questions while completing the above form, please simple leave that section or line blank. Once you return the form to our office, we will review the form and if needed, call you for clarification regarding any of the information provided or missing information.

To return the form to us, simply use whichever of the following methods that is most convenient for you: