LINDA SOMMERS GREEN

Attorney at Law

200 Union Boulevard, Lakewood, Colorado 80228

(303) 984-9900 ∙ Facsimile (866) 399-3560 ∙ www.coloradowills.org

ESTATE PLANNING DESIGN WORKSHEET

Please provide information that is as complete and accurate as possible. If you are unsure about exact information, please tell me and give me the best possible assessment. When more exact information is required, you will need to be more precise. Some of these questions may require additional room, so please feel free to elaborate on any question either on the back side of this checklist or on separate paper.

We realize that the questionnaire may seem fairly intrusive. Keep in mind, however, that the more complete the information, the better it will equip both you and me throughout the planning process. Your information will be kept confidential by my office unless you authorize or request its release to others.

Today’s Date: __________________

Who can we thank for referring you to our office?

Have you visited our website? Yes/No

Full Name: Nickname(s):

County of Residence: Email Address:

Home Address: Phone:

Fax:

Occupation: ________________________________

Employer: Phone:

Prefer to be called: Home Office

Prefer correspondence sent: Home Office Military Service Record: ________________

Date of Birth: _________________ Place of Birth: ______________________________

Social Security Number: ______________________

Name of Primary Care Provider:________________ Phone Number:____________________

Address:___________________________________________________

Are you a U.S. Citizen? Yes/No Are you a United States Resident? Yes/No

If married previously, indicate whether:

prior marriage ended in divorce ________________date of divorce

prior marriage ended with death of spouse

««««««««««««««««««««««««««««««««««««««««««

If married, complete the following for spouse:

Full Name: Nickname(s):

Email Address: ___________________________ Phone Number: _________________

Fax Number: ____________________

Occupation:

Employer: Phone:

Prefer to be called: Home Office

Prefer correspondence sent: Home Office Military Service Record: _______________

Date of Birth: _________________ Place of Birth: ______________________________

Social Security Number: ______________________

Name of Primary Care Provider:________________ Phone Number:_____________________

Address:_________________________________________________________

Are you a U.S. Citizen? Yes/No Are you a United States Resident? Yes/No

If married previously, indicate whether:

prior marriage ended in divorce ________________date of divorce

prior marriage ended with death of spouse

«««««««««««««««««««««««««««««««««««««««««««

Have you entered into any pre-nuptial or post-nuptial agreements?

Marriage Date: ______________________ Marriage Place:

Any other information that may be pertinent:

______________________________________________________________________________

«««««««««««««««««««««««««««««««««««««««««««

Please complete the following for each of your children:

Child of

Birth _ Male/ Husband/

Full Legal Name of Child Date Female Wife/Both

______________________________ __________ M/F _________ H/W/B Adopted/Disabled/Deceased/Disinherit?

______________________________ __________ M/F ________ H/W/B Adopted/Disabled/Deceased/Disinherit?

______________________________ __________ M/F _________ H/W/B Adopted/Disabled/Deceased/Disinherit?

______________________________ __________ M/F ________ H/W/B Adopted/Disabled/Deceased/Disinherit?

______________________________ __________ M/F _________ H/W/B Adopted/Disabled/Deceased/Disinherit?

«««««««««««««««««««««««««««««««««««««««««««««««

Other Considerations:

Advisors:

Accountant________________________ Broker_____________________________

Life Insurance______________________ Trust Officer_______________________

Commercial bank___________________ Other Attorney_____________________

Real Estate Agent___________________

Existing Documents:

Will - Date____________________ Location:_____________________

Living Trust - Date_____________ Location:_____________________

ILIT - Date_____________________ Location:_____________________

Medical Power of Attorney - Date______________ Location:____________________

General Power of Attorney - Date______________ Location:____________________

Living Will - Date______________ Location:_____________________

Real Estate:

Please list the location of all real estate presently owned and indicate how each is titled? i.e. tenants in common, joint tenancy, etc.

______________________________________________________________________________

«««««««««««««««««««««««««««««««««««««««««««

Personal estate planning objectives

State to whom you want your assets to go upon your death. If you are married, I will automatically assume your primary beneficiary is your spouse first. If this is not the case, please be sure to raise this issue with me when we meet.

Choice of Disposition:

Share of If they die first where Level of

Full Legal Name Estate does their share go? Distribution:

____________________________ _________ ___________________ 1^st, 2^nd, 3^rd, 4^th

Any Charitable Preferences?

«««««««««««««««««««««««««««««««««««««««««««

Family Residence (If you have minor children):

Disposition of the family home upon your death?_____________________________________

Disposition upon your spouse’s death?______________________________________________

««««««««««««««««««««««««««««««««««««««««««

Personal Representative (also known as Executor). Whom do you wish to wind up your affairs at your death? These duties would include: assuring that your assets are collected; claims, expenses, and estate and inheritance taxes are paid; and final distribution of your property to beneficiaries, trustees or others you have named. It is a task of limited duration, substantial responsibility, and much work.

Name, address and telephone number of each individual you would like to serve as personal representative of your estate: ** Your spouse is automatically named as first choice unless you indicate otherwise.

Telephone Serve Alone

Full Legal Name Number or Jointly

________________ _____________ _________ Primary/1st Alternate/2nd Alternate/3rd Alternate

Do you want your personal representative to be reimbursed for the time they spend on administering your estate? Yes/No

Do you want your personal representative to be reimbursed for expenses (i.e., travel expenses, etc.) that is spent in order to administer your estate? Yes/No

«««««««««««««««««««««««««««««««««««««««««««

Guardians for minor children. If you have minor children, whom do you wish to take care of your children in the event of your death and/or your spouse's death? ** Your spouse is automatically named as first choice unless you indicate otherwise.

Telephone Serve Alone

Full Legal Name Number or Jointly

________________ _____________ _________ Primary/1st Alternate/2nd Alternate/3rd Alternate

«««««««««««««««««««««««««««««««««««««««««««

Trustees. This person has the responsibility for the long-range management of property that is to be held in trust for the benefit of beneficiaries of trusts you may create. Depending on the terms of the trust, there may be adverse tax consequences if a trustee has an interest or possible interest in the trust, although usually if the trustee's discretion is limited, those adverse tax consequences are similarly limited. Trustees can be corporations (qualified to act) or individuals. You may choose to have co-trustees, one of which may or may not be a corporation. In general, choose a trustee with the following qualities: integrity, mature judgment, fiscal responsibility, and reasonable business and investment acumen. If you wish to select co-trustees, you may want to choose them for how well their individual strengths complement one another. ** Your spouse is automatically named as first choice unless you indicate otherwise.

Telephone Serve Alone

Full Legal Name Number or Jointly

________________ _____________ _________ Primary/1st Alternate/2nd Alternate/3rd Alternate

«««««««««««««««««««««««««««««««««««««««««««

General Power of Attorney:

A General Durable Power of Attorney (GDPA) is a document in which one person (the Principal) gives legal authority to another person (the Agent) to act on the Principal's behalf. Generally this document will become effective and will continue in effect after you become incapacitated. It terminates when you die, when you cancel it (you can cancel it at any time), or at a time you specify. ** Your spouse is automatically named as first choice unless you indicate otherwise.

Telephone Serve Alone

Full Legal Name Number or Jointly

________________ _____________ _________ Primary/1st Alternate/2nd Alternate/3rd Alternate

Medical Power of Attorney:

A Medical Durable Power of Attorney (MDPA) is used to deal with health-care planning. It allows you to appoint someone else to make health-care decisions for you, if you become incapable of making that decision. You can give someone powers relating to things like nursing homes, surgeries, and artificial feeding. A copy should be put in your doctor's medical file. ** Your spouse is automatically named as first choice unless you indicate otherwise.

Telephone Serve Alone

Full Legal Name Number or Jointly

________________ _____________ _________ Primary/1st Alternate/2nd Alternate/3rd Alternate

«««««««««««««««««««««««««««««««««««««««««««

Living Will:

A Living Will is a written declaration that allows you to state in advance your wishes about the use of life-prolonging medical care if you become terminally ill and unable to communicate, persistently vegetative, or irreversibly comatose. It permits your wishes to be carried out even if you become unable to state them.

Have you signed any document indicating your wishes regarding "heroic" or extraordinary measures to save your life in the event of a catastrophic illness or injury? Yes/No

If not, would you like to do so? Yes/No

Do you want to make anatomical gifts? ________ For transplantation purposes ___________

For research purposes_________________

«««««««««««««««««««««««««««««««««««««««««««

Are there any facts or matters that do not seem to be covered above? If so, please comment here.

«««««««««««««««««««««««««««««««««««««««««««

Financial Analysis

CASH & SAVINGS

Checking Account $_______________________

Certificates of Deposit ________________________

Treasury Bills ________________________

Credit Union ________________________

Money Market ________________________

Savings Account ________________________

Total $____________________

MARKET SECURITIES

Stocks $_______________________

Bonds ________________________

Mutual Funds ________________________

Annuities ________________________

Whole/Universal Life ________________________

Gold & Silver ________________________

Total $____________________

REAL ESTATE (Other Than Home)

Type City Market Value - Mortgage = Equity

_______________ _______________ $______________ $______________ $______________

_______________ _______________ _______________ _______________ _______________

Total Equity $_______________

FIXED & OTHER

Business Interest $_______________________

Limited Partnerships ________________________

First & Second Trust Deeds ________________________

Notes Due ________________________

Total $_________________

Home - Market Value $____________

Less Mortgage $____________

Equity $____________

Personal Property $____________

Total $____________________

RETIREMENT PLANS

IRA $_______________________

Keogh ________________________

SEP ________________________

401(k) ________________________

Profit Sharing Plan ________________________

TSA ________________________

ESOP ________________________

PASOP ________________________

Deferred Compensation ________________________

Pension ________________________

Total $____________________

LIFE INSURANCE

Face Value Cash Value

Client _ _

_____________ _____________

Spouse _____________ _____________

_ _

Possible Future Inheritance $____________________

Gross Annual Income of Client $____________________

Gross Annual Income of Spouse $____________________

«««««««««««««««««««««««««««««««««««««««««««

If your estate is worth more than $1,500,000 and you choose not to execute trusts and related estate planning documentation appropriate for that size of estate do you understand that there may be serious tax implications as a result of your decision not to plan accordingly? _____ Yes _____No

________________________________

Client Signature

Certificates of Deposit ________________________

Limited Partnerships ________________________

Face Value Cash Value

Client _____________ _____________

_____________ _____________

Client _ _

_ _