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1 FROM THE LAW OFFICES OF DAVID A. ZIPP, P.C. OR ESTATE PLANNING QUESTIONNAIRE Name: SS# Birth date/place: Citizenship: Address: Spouse: Birth date/place: SS# Citizenship: Occupation-Client: Name of Employer Business: Occupation-Spouse: Name of Employer Business: Home Phone: (Client): (Spouse) Business Phone: Fax: Car or Cellular Phone: Business Phone: Fax: Car or Cellular Phone: Prior Marriage(s): (Give former spouse s name, address, date of divorce) Children: Name Birth date Other Parent Domicile Other dependents: Name Relationship Other family of Client Spouse Grandparents: Parents: Brothers/Sisters: 1

2 Grandchildren: Great-grandchildren: *If deceased, please indicate by circling the relative s name. Community property: State whether you have lived in any of the following community property jurisdictions (Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, or Wisconsin) and give dates of residency. If you have lived abroad, please state the country or countries in which you lived and the dates of your residence abroad. Prenuptial or other property disposition agreement: no yes (if yes, describe briefly) Special family problems: (disability, family dispute, etc.) Asset Information Careful attention should be given to identifying the ownership of assets -- those solely in client's name, those in name of spouse and those held jointly by client with another person ("jointly" meaning in a form of ownership under which the surviving joint owner becomes the sole owner of the entire asset). Use current market values; if joint assets are substantial, indicate which owner paid for them, also identify the joint owner if someone other than client's spouse. Client Spouse Joint Name of Joint Owner or Beneficiary Checking accounts: $ $ $ Savings accounts: $ $ $ Stocks: $ $ $ Bonds: $ $ $ Mutual Funds: $ $ $ Treasury bills, bonds: $ $ $ Other Securities: $ $ $ Gold or silver bullion, foreign currency $ $ $ Employee benefits: Group life insurance: $ $ $ Pension plan $ $ $ Profit sharing plan: $ $ $ Savings plan: $ $ $ 2

3 Stock options: $ $ $ Other: $ $ $ Other insurance policies $ $ $ Other retirement plans IRA plans $ $ $ Other $ $ $ Client Spouse Joint Name of Joint Owner or Beneficiary Other death benefits (union or other sources): $ $ $ Mortgages, leases, copyrights, trademarks, patents, franchises (which you own): $ $ $ Business interests (owned in whole or part--attach description): $ $ $ Tangibles: Cars, trucks, trailers, and other motor vehicles $ $ $ Boats and aircraft $ $ $ Personal effects (furs, jewelry, clothing) $ $ $ Guns, valuable pets, other hobby equipment $ $ $ Collections: Artwork $ $ $ Other : $ $ $ Household effects: $ $ $ Office contents: $ $ $ Real estate -- indicate value less mortgage $ $ $ Coop/condo -- indicate value less mortgage $ $ $ Taxable beneficial interests in existing estates and trusts created by others (describe): $ $ $ Future possible inheritances: $ $ $ Other assets (describe): TOTAL ASSETS: $ $ $ 3

4 Location of Assets One of the more difficult (and costly) tasks often facing Executors is to locate the assets of a person no longer here. The following pages are designed to alleviate this problem. A copy of the filled-in pages will be returned to you to keep with your records and to up-date from time to time. Checking Accounts (name of bank, location, name of account holder): Savings Accounts (name of bank, location, name of account holder): Bank account pass books (where kept): Safe deposit box (location, name of box holder(s), who has access, location of keys): Private safe (location, who has access): Securities (where kept): Real estate -- Location: Other real estate -- Location: Other real estate -- Location: Insurance policies-- life, health and accident (where kept): Other insurance policies--home, rental, auto, business (where kept): Contracts and business agreements (where kept): Income tax returns for prior years (where kept): Jewelry and other valuable tangibles (where kept): Original copy of current wills (where kept): Trust agreements (where kept): Cemetery plot (location of plot and deed; care arrangements): Military discharge papers (where kept): Birth certificates (where kept): Marriage certificates (where kept): Divorce papers (where kept): Employee benefit statements (where kept): Naturalization papers (where kept): Passports (where kept): Adoption papers (where kept): 4

5 Names and addresses of advisers: Stockbrokers/Investment Advisers: Insurance representatives: Accountant: Family Physician: Literary and other agents: Clergyman: Personal secretary: Mortgagee: Insurance Information Type of Policy (term, whole life, second to die, etc.): Type of Policy (term, whole life, second to die, etc.): Type of Policy (term, whole life, second to die, etc.): Please use extra pages if necessary. It will be very helpful to your loved ones or the Executor of your estate to make photo copies of all of your current retirement, life insurance, and other records. While obviously not current many years later when you pass on, copies of these documents will be invaluable to your loved ones as you are leaving a road map for them to find and properly disburse your assets. Remember, you will not be around to answer simple questions. Also, please if nothing else, NEVER, NEVER, NEVER store your Last Will in a Safe Deposit Box! If I can help at any time, me at DavidZipp@lawyer.com or call me at