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Estate Planning

Please fill out completely and fax or mail back. This form is extremely important. Your accuracy and completeness in responding will help me best represent you. ALL THE PAGES AND SECTIONS OF THIS FORM MUST BE COMPLETED PRIOR TO SEEING THE ATTORNEY. WRITE YOUR SPECIFIC QUESTIONS AT THE END OF THE LAST PAGE. PLEASE HELP YOURSELF TO THE FREE INFORMATION BROCHURES IN THE RECEPTION AREA. PLEASE PRINT CLEARLY Your Full Name: [Person Filling out Form] ______________________________________________________ First Last Street Address: ________________________________________ City ____________________ State ____ Zip Code _____________ Telephone Numbers: Cell: __________________________________ Day: ____________________ /Night: ________________________ E-mail address: __________________________________________ Referred By: ___________________________________________ Todays Date ___________________________________________ 1. Name of person planning for if other than person filling out this interview sheet: ____________________________________________________________ 2. Current address and phone for person whom Estate Planning is sought: ____________________________________________________________ ____________________________________________________________ 3. Relationship of person filling out this interview sheet: ____________________________________________________________ 4. Special medical or financial needs of person, spouse and dependents: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ASSETS 5. Stocks, bonds and other securities. How Registered. Approximate Amount of Each. (Joint - Survivorship - P.O.D. - Trust - Custodial) ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ 6. Real Estate: Location and General Description - Record Owners - How and When Acquired Estimated Value - Mortgages, Approximate Amount of Each: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ 7. Insurance policies, pensions, retirement and death benefits: (Identification and beneficiary) COMPANY AMOUNT OF POLICY BENEFICIARY ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ 8. Bank and Savings & Loan Association Accounts: Savings - Time Cert. - Checking - other. How registered (Joint, Survivorship, Trust, Custodial) BANK APPROXIMATE AMOUNT BENEFICIARY ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ 9. Major Personal Effects: Including Furs, Jewelry, Art, Cash on Hand and other items of Substantial Value and the Approximate Amount of Each: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ 10. Other Investments: Nature and in What Names(s) Held and the Approximate Amount of Each: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ 11. Safe Deposit Box: Location and How Registered: ____________________________________________________________ ___________________________________________________________ 12. Liabilities More Than $2,000.00: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ 13. Estimated Gross Estate: $_________________________________________________________ 14. A. Is there a Will? _____ Did you bring a photocopy? ____ B. Is there a Power of Attorney? _____ Did you bring a copy? ____ C. Do You Have a Copy of the Deed? ________ D. Did You have/ bring a List of Assets. 15. PLEASE USE THIS PAGE TO WRITE YOUR SPECIFIC QUESTIONS FOR THE ATTORNEY: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ESTATE PLANNING The estate may be subject to Federal Estate Taxation if the total of assets exceeds $200,000. If the assets exceed $2,000,000 and you desire estate planning to avoid or reduce your estate tax or require a Trust to protect a spouse, please advise Mr. Vercammen. A Standard Will is not designed to address estate tax issues. We do not do Tax Planning or Medicaid Planning.