Samuel T. Swansen, P.C.
Attorney and Counselor at Law
ESTATE PLANNING CLIENT INFORMATION WORKSHEET -------------------------------The purpose of this Worksheet is to help prepare you for our upcoming estate planning consultation and to provide us with important personal and asset information related to your estate so that we are able to properly advise you on your situation. It is very important that you bring the completed Worksheet to our planning meeting.
-------------------------------Samuel T. Swansen, PC 660 Sentry Parkway, Suite 200 Blue Bell, PA 19422 (610) 834-9810 (610) 834-9812 fax sam@samswansen.com
FAMILY INFORMATION
YOU
Full Name Name you want us to put on your documents ___________________________________ Birth Date Soc. Security No. Employer Occupation Work Phone U.S. Citizen YES NO Home Address City, State, Zip County of Residence Home Phone CHILDREN Full Name Parent (H, W or Joint) Birthdate _____________________ _____________________ _____________________ _____________________
YOUR SPOUSE
Full Name_____________________________ Name you want us to put on your documents ______________________________________ Birth Date______________________________ Soc. Security No. ________________________ Employer_______________________________ Occupation______________________________ Work Phone_____________________________ U.S. Citizen YES NO Date of Marriage_________________________ Email Address___________________________ How did you hear about us?
If any of your children or dependents are under the age 18, whom do you wish to name as guardian? Name: Name: PROFESSIONAL ADVISORS Accountant Financial Planner/Stock Broker Insurance Agent Banker Physician Relationship: ___________________________ Relationship: ___________________________ PHONE NUMBER ___________________________ ___________________________ ___________________________ ___________________________ ___________________________
IMPORTANT QUESTIONS Have you or your spouse ever had a Will or Trust? Do any of your children/beneficiaries receive government support or benefits because of a disability or handicap? Do any of your children/beneficiaries have special educational, medical or physical needs? Do you have any adopted children? Have you or your spouse ever signed a pre or post marital agreement? Have you or your spouse ever been divorced? Have you or your spouse ever been widowed? If you are married now, do you or your spouse have children from a previous marriage? Have you or your spouse ever lived in a community property state (i.e., LA, TX, NM, AZ, CA , WA, NV, WI, AK) Do you own or operate a family business? Have you or your spouse ever filed a federal or state gift tax return? Are there any charities or causes which you would like to support? Have you inherited property from anyone within the last ten years? Do you expect any inheritance in the near future? Do you have disability insurance? Do you have long-term care insurance? Do you have umbrella insurance? YES NO
YES
NO
YES YES YES YES YES
NO NO NO NO NO
YES
NO
YES YES YES YES YES YES YES YES YES
NO NO NO NO NO NO NO NO NO
If you answered a YES to any of these questions or have any SPECIAL concerns, please share any details which you think would be helpful.
YOUR ESTATE PLANNING PRIORITIES Please rank your priorities in your estate planning: "1" being very important; "2" being somewhat important; "3" being not very important _____ Providing health care instructions in case of my disability _____ Maintaining family income in the event of my disability _____ Maintaining family lifestyle in the event of my death _____ Minimizing probate _____ Reducing estate taxes _____ Providing funds to pay final expenses upon my death _____ Providing for my children’s education _____ Providing for a gift-giving program _____ Planning for creditor protection _____ Preventing certain individuals from inheriting my estate _____ Ensuring that certain individuals inherit my estate _____ Providing for asset management for my beneficiaries _____ Planning for the event of disability of a loved one _____ Leaving a legacy: What do you value that you’d like to pass on? Most of our estate planning includes a will. Please indicate whom you would choose to act as your executor, as well as successor executor (for married couples, your spouse is usually your first executor/executrix). Executor/Successor Executor(s) 1. _____________________ 2. ______________________ 3. ______________________
If you are interested in a trust, please also indicate your choice of trustee and successor trustee (again, for married couples, your spouse is usually considered to be your primary trustee). Trustee/Successor Trustee(s) 1. _____________________ 2. ______________________ 3. ______________________
FINANCIAL INFORMATION REAL PROPERTY Address Title on Deed Approx. Value Approx. Mortgage Bal. ____________ ____________ ____________
BANK ACCOUNTS Bank Account / Type
Owner
Approx. Balance ____________ ____________ ____________
RETIREMENT ACCOUNTS Institution / Type
Owner
Approx. Balance ____________ ____________ ____________
STOCK OPTIONS INCENTIVE STOCK OPTIONS Grantor Grant Date
Vesting Date
Expiration Date ____________
Are they transferable/assignable? _____ Yes _____ No Please bring company statement regarding the plan. NONQUALIFIED STOCK OPTIONS Grantor Grant Date
Vesting Date
Expiration Date ____________
Are they transferable/assignable? _____ Yes _____ No Please bring company statement regarding the plan. BROKERAGE ACCOUNTS Institution / Type
Owner
Approx. Balance ____________ ____________ ____________
INSURANCE POLICIES Institution / Type
Owner
Approx. Balance ____________ ____________ ____________
BUSINESS INTERESTS Name of Business
Type of Business
Ownership Interest
Approx. Value ____________ ____________ ____________
MOTOR VEHICLES Make/Model/Year
Owner Shown on Title
Approx. Value ____________ ____________ ____________
PERSONAL PROPERTY & OTHER ASSETS Description Owner
Approx. Value ____________ ____________ ____________ ____________ AMOUNT
INCOME & SAVINGS
Husband or Single Person Gross Income Per Year ............................................................_______________________ Amount Saved or Invested Per Year........................................_______________________ Wife Gross Income Per Year ............................................................_______________________ Amount Saved or Invested Per Year........................................_______________________ Total Gross Income.............................._______________________ Total Saved/Invested............................_______________________
SUMMARY OF VALUES Asset Husband/ or Single Person Joint Wife
Real Property (in state/out state) Bank Accounts Retirement Accounts Stock Options Incentive Non-Qualified Brokerage Accounts Life Insurance Policies
Business Interests Motor Vehicles Personal Property/Other Assets TOTAL ASSETS Liabilities Real Property Mortgage Auto Loans Other TOTAL LIABILITIES NET WORTH ___________ ___________ ___________ ___________ ___________ ___________ ___________ Husband/ or Single Person ___________ Joint ___________ Wife