ADDRESSES:_______________________________________________________

GRANDCHILDREN:

NAME(S)___________________________________________________________

DOB:________________________                MARITAL STATUS:______________

ADDRESSES:________________________________________________________

PARENTS NAMES AND ADDRESSES:___________________________________

____________________________________________________________________

BROTHERS AND SISTERS NAMES AND ADDRESSES______________________ _____________________________________________________________________

ASSETS:                                                                        VALUE        OWNERSHIP

                                                                                                        Husband  Wife     Joint

REAL ESTATE:                                      

________________________________________    _______        _____     ___      ___

________________________________________    _______        _____      ___     ___

________________________________________    _______        _____       ___    ___

CHECKINGS/SAVNGS/FINANCIAL ACCOUNTS:

_________________________________________  _______        _____       ___    ___

_________________________________________  _______        _____       ___    ___

_________________________________________  _______        _____       ___    ___

STOCKS AND BONDS:_____________________  _______        _____       ___    ___

_________________________________________   _______        _____      ___    ___

_________________________________________   _______        _____      ___    ___

BUSINESS INTERESTS:_____________________   _______       _____       ___   ___

_________________________________________

PENSION/PROFIT SHARING PLANS:

_________________________________________    _______       _____       ___   ___

_________________________________________    _______       _____       ___   ___

PERSONAL EFFECTS (i.e. car, collections, jewelry, valuables) ____________________

______________________________________________________________________

LIFE INSURANCE  (Provide Company, Policy #, Face Value, Ownership and Beneficiary information):___________________________________________________________

_____________________________________________________________________

LIABILITIES:

LOANS:_____________________________________________________________

MORTGAGES:________________________________________________________

SPECIFIC BEQUESTS OR DEVISES (particular items of property of gifts of money that you want to go to specific people):__________________________________________

____________________________________________________________________

CHARITABLE BEQUESTS OR DEVISES:__________________________________

____________________________________________________________________

RESIDUARY ESTATE (MONIES AND PROPERTY NOT SPECIFICALLY BEQUEATHED):

1.  PRIMARY BENEFICIARIES:__________________________________________

2.  ALTERNATE BENEFICIARIES:________________________________________

EXECUTOR:__________________________________________________________

ALTERNATE EXECUTOR________________________________________________

GUARDIAN:__________________________________________________________

ALTERNATE GUARDIAN:_______________________________________________

TRUSTEE (IF APPLICABLE):_____________________________________________

ALTERNATE TRUSTEE:_________________________________________________

BURIAL INSTRUCTIONS,IF DESIRED:____________________________________

_____________________________________________________________________

DO YOU CURRENTLY HAVE A WILL?__________

DO YOU CURRENTLY HAVE A LIVING WILL, POWER OF ATTORNEY FOR HEALTH CARE, AND/OR POWER OF ATTORNEY FOR PROPERTY?__________

DURABLE POWER OF ATTORNEY:

HEALTH CARE AGENTS:________________________________________________

PROPERTY AGENTS:___________________________________________________

ADDITIONAL CONCERNS:______________________________________________

______________________________________________________________________