1 st Person/Spouse (Him) 2 nd Person/Spouse (Her)
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1 1 st Person/Spouse (Him) 2 nd Person/Spouse (Her) Middle Initial Middle Initial: Date of birth: Date of birth: US Citizen: Y / N US Citizen: Y / N First Marriage: Y / N First Marriage: Y / N Children prior current marriage: Y / N Children prior current marriage: Y / N Home address: Home address: Cell Phone: Home Phone: Other: Mailing Address (if different from home address): Cell Phone: Home Phone: Other: Mailing Address (if different from home address): 1
2 Children s Names 1 st Child s 2nd Child s Married: Y / N Married: Y / N Children to this marriage: Y / N Children to this marriage: Y / N 3 rd Child s 4th Child s Married: Y / N Married: Y / N Children to this marriage: Y / N Children to this marriage: Y / N 2
3 Division of Estate Equally to all children Y / N Unequally: specify to whom and by percentage Relationship: Relationship: Percentage % Relationship: Percentage % Relationship: Percentage % Per Stirpes: Y / N (Means equally by representation) further defined as: if a child of yours passes away before you then that child s share will go to that child s children. Percentage % Pro Rata: Y / N (Meaning equally among the surviving children or grandchildren of the client). Other bequests: 3
4 1 st Person Trustees (Person or persons in charge of management of the trust and distribution to beneficiaries) 2 nd Person 3 rd Person When there are more than one trustee serving at a time there can be co-trust authority or there can be governance by a committee. When there is governance by a committee there can be unevenly weighted authority. Also, in either case of cotrustee or governance by committee there can be a neutral third party to act as a tie breaker in case there is a deadlock in deciding whether or not to do an act. Agents His Health Care Power Of Attorney 1 st Person 2 nd Person 3 rd Person 4
5 Her Health Care Power Of Attorney 1 st Person 2 nd Person 3 rd Person His Durable Power Of Attorney 1 st Person 2 nd Person 3 rd Person 5
6 Her Durable Power Of Attorney 1 st Person 2 nd Person 3 rd Person Guardianship (Only for clients with minor children) Primary Guardian: Only name one person even if that person is married. For example, if it s your sister, only name your sister and not your sister and her husband. Primary Guardian Secondary Guardian Tertiary Guardian 6
7 Legacy and Succession Planning Family Bank Legacy Distribution for Shift Evolution Members Only Do you want your children to be restricted to the provisions of the Shift Evolution Bank? Y / N Do you want to retain some provisions for distribution without the restrictions of the Shift Evolutions Bank? Y / N Specify what provisions you would like to change under the Shift Evolution provisions: Income First Person/Spouse income (His) Second Person/Spouse income (Hers) Income amount (monthly): $ Source: Income amount (monthly): $ Source: Income amount (monthly): $ Source: Income amount (monthly): $ Source: Income amount (monthly): $ Source: Income amount (monthly): $ Source: Total: Total: 7
8 Primary Residence: Asset Inventory Real Estate Value (Fair Market Value): Debt: Secondary Residence: $ Value (Fair Market Value): Debt: Tertiary Residence (Lake House, Vacation Home, Summer Camp): $ Value (Fair Market Value): Debt: $ Investment Real Estate 1 st : Name on the Deed: Value (Fair Market Value): Debt: 2 nd : Name on the Deed: $ Value (Fair Market Value): Debt: 3 rd : Name on the Deed: $ Value (Fair Market Value): Debt: $ 8
9 Business Holdings 1 st Name of Company: Ownership type: LLC Corporation Sole Proprietorship FLP Other: Value (Fair Market value): Debt: Inventory: Service Type: Percentage of ownership: % 2 nd Name of Company: Ownership type: LLC Corporation Sole Proprietorship FLP Other: Value (Fair Market value): Debt: Inventory: Service Type: Percentage of ownership: % 9
10 3 rd Name of Company: Ownership type: LLC Corporation Sole Proprietorship FLP Other: Service Type: Value (Fair Market value): Debt: Inventory: Percentage of ownership: % 4 th Name of Company: Ownership type: LLC Corporation Sole Proprietorship FLP Other: Service Type: Value (Fair Market value): Debt: Inventory: Percentage of ownership: % His Life insurance Amounts $ Type of insurance: Cash Value Whole Life / Term / Index Universal Life Her Life insurance Amounts $ Type of insurance: Cash Value Whole Life/Term/Index Universal Life 10
11 Investment Assets Please indicate either Retirement or Non-Retirement Account (Retirement Accounts: IRA,401K, Roths) Investment Amount: Investment Amount: Adviser: Firm: Adviser: Firm: Investment Amount: Adviser: Firm: Investment Amount: Adviser: Firm: Investment Amount: Adviser: Firm: Investment Amount: Adviser: Firm: 11
12 Name of Bank: Local Bank Account (Please do not list accounts numbers) Name of Bank: Checking, CD, Savings Amount on accounts: Name of Bank: Checking, CD, Savings Amount on accounts: Name of Bank: Checking, CD, Savings Amount on accounts: Checking, CD, Savings Amount on accounts: Collectibles, Antiques, Tools, Vehicles, etc. List with details and estimated values Special Instructions: 12
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