ESTATE PLANNING QUESTIONNAIRE

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Grant Richards
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Annapolis Office: 1835 orest Drive, Suite D-3 Annapolis, D 21401 Eastern Shore Office: 124 E. arket Street Salisbury, D 21801 ailing Address: Post Office Box 6721 Annapolis, D 21401 www.

1 Annapolis Office: 1835 orest Drive, Suite D-3 Annapolis, D Eastern Shore Office: 124 E. arket Street Salisbury, D ailing Address: Post Office Box 6721 Annapolis, D Phone: (443) ax: (443) ESTATE PLANNING QUESTIONNAIRE *K. Lynn Carter Shereese atthews Admitted: State of aryland *United States District Court for the District of aryland THIS OR WAS COPLETED ON / / BY: Your ull Name: CLIENT S NAE SPOUSES NAE (if applicable) Spouse s ull Name I APPLICABLE, HAVE YOU AND YOUR SPOUSE SIGNED A PRE OR POST NUPTIAL AGREEENT? AILING AND PHONE INORATION STREET ADDRESS CITY STATE ZIP CODE COUNTY HOE PHONE EAIL ADDRESS YOUR WORK PHONE YOUR CELL PHONE SPOUSES WORK PHONE SPOUSE S CELL PHONE YOUR PERSONAL INORATION DATE O BIRTH SOCIAL SECURITY # DO YOU HAVE ANY SERIOUS HEALTH PROBLES? WHERE ARE YOU EPLOYED? ARE YOU A U.S. CITIZEN? YOUR SPOUSES PERSONAL INORATION (if applicable) DATE O BIRTH SOCIAL SECURITY # DOES YOUR SPOUSE HAVE ANY SERIOUS HEALTH PROBLES? WHERE IS YOUR SPOUSE EPLOYED? IS YOUR SPOUSE A U.S. CITIZEN? YOUR ACCOUNTANT S INORATION NAE ADDRESS PHONE EAIL YOUR INANCIAL ADVISOR S INORATION NAE ADDRESS

2 PHONE EAIL YOUR INSURANCE AGENT S INORATION NAE ADDRESS PHONE EAIL CHILDREN S INORATION CHILDREN PARENT CHILD S ULL NAE ARRIED AND NAE O SPOUSE BIRTH DATE SEX ARE ANY CHILDREN HANDICAPPED AND/OR RECEIVING GOV T BENEITS? (I WHICH CHILD?) DO YOU HAVE ANY PREDECEASED CHILDREN? GRANDCHILDREN (I APPLICABLE) PARENT S NAE GRANDCHILD S ULL NAE AND AGE PARENT S NAE GRANDCHILD S ULL NAE AND AGE INORATION OR PARENTS AND SIBLINGS PARENTS AND SIBLINGS E E E E E WHO S RELATIVE? Y SPOUSE Y SPOUSE Y SPOUSE Y SPOUSE Y SPOUSE RELATIVE S ULL NAE AGE RELATIONSHIP ATHER ATHER ATHER ATHER ATHER Page 2 of 7

3 E E Y SPOUSE Y SPOUSE ATHER BR ATHER BR SISTER SISTER I APPLICABLE, ARE YOU AND/OR YOUR SPOUSE EXPECTING TO RECEIVE AN INHERITANCE UPON THE DEATH O A PARENT? INCOE INORATION RECIPIENT SOURCE ON INCOE (Social Security, wages, pension) AOUNT ($)/month E Y SPOUSE E Y SPOUSE E Y SPOUSE E Y SPOUSE E Y SPOUSE E Y SPOUSE E Y SPOUSE LIABILITIES WHO IS LIABLE? TYPE O LIABILITY (mortgage, credit cards, promissory loan) CURRENT BALANCE OWED E Y SPOUSE E Y SPOUSE E Y SPOUSE E Y SPOUSE E Y SPOUSE E Y SPOUSE E Y SPOUSE E Y SPOUSE Page 3 of 7

4 REAL ESTATE (including timeshares, vacant lots, etc.) OWNER IS (check one) E Y SPOUSE E Y SPOUSE E Y SPOUSE E Y SPOUSE ASSET INORATION PURPOSE LOCATION O REAL ESTATE (residence, vacation, or rental) ARKET VALUE ORTGAGE OWED BANK ACCOUNTS (including checking, savings, certificate of deposits, money markets, etc.) TYPE O ACCOUNT OWNER IS (check one) NAE O BANK (check one) E Y SPOUSE ONEY ARKET E Y SPOUSE E Y SPOUSE E Y SPOUSE E Y SPOUSE E Y SPOUSE E Y SPOUSE E Y SPOUSE ONEY ARKET ONEY ARKET ONEY ARKET ONEY ARKET ONEY ARKET ONEY ARKET ONEY ARKET CURRENT BALANCE RETIREENT PLAN ACCOUNTS (IRA, 401(K), 403(B), TSP, etc.) OWNER IS (circle one) NAE O BROKERAGE ACCOUNT OR COPANY BENEICIARY Primary Secondary ARKET VALUE E E E Y SPOUSE Y SPOUSE Y SPOUSE Page 4 of 7

5 E Y SPOUSE E Y SPOUSE STOCKS AND BONDS T IN RETIREENT PLAN ACCOUNT (including brokerage accounts, stock options, etc.) OWNER IS (check one) NAE O BROKERAGE COPANY OR STOCK ARKET VALUE E Y SPOUSE E Y SPOUSE E Y SPOUSE E Y SPOUSE E Y SPOUSE E Y SPOUSE E Y SPOUSE E Y SPOUSE ANNUITIES OWNER IS (check one) NAE O COPANY BENEICIARY ARKET VALUE E E E E E E E E Y SPOUSE Y SPOUSE Y SPOUSE Y SPOUSE Y SPOUSE Y SPOUSE Y SPOUSE Y SPOUSE BUSINESS INTERESTS (including S Corps, C Corps, s, Partnerships, etc.) TYPE O INTEREST NAE (e.g., Smith Land, Inc.; Smith Land, ) NAE O OWNERS & EACH OWNER S SHARE ARKET VALUE S Corp C Corp Partnership Other How many employees? Do you have a written agreement with the other owners? S Corp C Corp Partnership Other How many employees? Page 5 of 7

6 Do you have a written agreement with the other owners? S Corp C Corp Partnership Other How many employees? Do you have a written agreement with the other owners? LIE INSURANCE OWNER IS (check one) NAE O LIE INSURANCE COPANY BENEICIARY Primary Secondary 1. E Y SPOUSE DEATH BENEIT Is the owner also the insured? 2. E Y SPOUSE Is the owner also the insured? 3. E Y SPOUSE Is the owner also the insured? 4. E Y SPOUSE Is the owner also the insured? 5. E Y SPOUSE Is the owner also the insured? 6. E Y SPOUSE Is the owner also the insured? 7. E Y SPOUSE Is the owner also the insured? Page 6 of 7

7 ISCELLANEOUS 1. Are you the beneficiary of any trust, whether or not you are presently receiving any income from the trust? 2. If applicable, is your spouse the beneficiary of any trust, whether or not you are presently receiving any income from the trust? 3. Have you made any gifts exceeding $13,000 in any one calendar year? TES 4. If applicable, has your spouse made any gifts exceeding $13,000 in any one calendar year? 5. Do you have long term care insurance e coverage? 6. If applicable, does your spouse have long term care insurance coverage? Page 7 of 7

Married? Husband's name Wife's name Mailing Address:

DATE COMPLETED: Date of Birth U.S. Citizen? Married? Husband's name Wife's name Mailing Address: email address Date and place of marriage Children Child's Date of Birth Married? Grandchildren Parent Grandchild's