ESTATE PLANNING FACT SHEET. Full Name: Primary Occupation: Address (Include Country): Business Address: Electronic Mail Address:

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1 Date: ESTATE PLANNING FACT SHEET CM#: I. Full Primary Occupation: Address (Include Country): Business Electronic Mail Telephone: Home: Business: Cell: Birthdate: U.S. Citizen: Yes No If No, Country: Single Widowed Divorced Safe Deposit Box: Yes No If yes, Name and Address of Institution: Page 1 of 15

2 CHILDREN (Indicate if Adopted) First Child Second Child Birthdate: Children: Names and Birthdates: Third Child Fourth Child Birthdate: Children: Names and Birthdates: Page 2 of 15

3 OTHER DEPENDENTS First Second Birthdate: Third Fourth Birthdate: II. PERSONAL ADVISORS Accountant Insurance Agent Firm: Facsimile: Page 3 of 15

4 Stock Broker Regular Physician Firm: Facsimile: Financial Planner Bank Officer Firm: Facsimile: PERSON RESPONSIBLE FOR EMPLOYMENT BENEFITS AT EMPLOYER S OFFICE Facsimile: Page 4 of 15

5 III. NOMINATIONS A. PERSONAL REPRESENTATIVE(S). If Co-Personal Representatives, indicate with an asterisk (*). Indicate successor(s) by number. Page 5 of 15

6 B. TRUSTEES. If Different from Personal Representatives. Page 6 of 15

7 C. ATTORNEY(S)-IN-FACT. For Durable Power of Attorney. Page 7 of 15

8 D. GUARDIAN(S) OF A MINOR CHILDREN (IF CHILDREN UNDER AGE 19) E. COMPENSATION. For Individuals. 1. Personal Representative Yes No If yes, conditions, if any: 2. Trustee Yes No If yes, conditions, if any Page 8 of 15

9 IV. ASSET/LIABILITY SUMMARY Assets/ Property Personal Effects Home (Principal) Other Real Estate Cash Bank Accounts Certificates of Deposit Marketable Securities (include retirement see page 10 for breakdown) Non-Marketable Securities Business Interests Other Assets (Brief Description) TOTAL Liabilities Current Debts Bank Loans Mortgages Payable Income Taxes (Include Possible Tax Shelter Liabilities) Other Debts (Brief Description) TOTAL Estimated Combined Present Net Worth Estimated Value of Estate Including Insurance and Employment Benefits If available, please attach financial statement and a copy of deeds including legal descriptions of any real property that you own (including home). Page 9 of 15

10 LIFE INSURANCE O = Other T = Trust E = Estate CH = Charity C = Child Indicate Insurance Agent: Date of this Valuation: Insured Company Policy Type and Number Face Amount Cash Value Loan Balance Owner T/O Beneficiaries CH/E/T/C/O Insured Company Policy Type and Number Face Amount Cash Value Loan Balance Owner T/O Beneficiaries CH/E/T/C/O Page 10 of 15

11 Insured Company Policy Type and Number Face Amount Cash Value Loan Balance Owner T/O Beneficiaries CH/E/T/C/O Insured Company Policy Type and Number Face Amount Cash Value Loan Balance Owner T/O Beneficiaries CH/E/T/C/O Page 11 of 15

12 RETIREMENT BENEFITS O = Other T = Trust E = Estate CH = Charity C = Child Indicate person(s) responsible for employee benefits: Participant Employer/Company Plan Type Accrued Benefits Cash Value Beneficiary CH/E/T/C/O Participant Employer/Company Plan Type Accrued Benefits Cash Value Beneficiary CH/E/T/C/O Participant Employer/Company Plan Type Accrued Benefits Cash Value Beneficiary CH/E/T/C/O Page 12 of 15

13 ESTIMATED INCOME FOR CURRENT YEAR Base Salary Bonus and Other Compensation Taxable Dividends and Interest Tax Exempt Income Capital Gains and Losses Other Income (Specify) TOTAL V. OTHER INFORMATION A. What are you estate planning objectives (help children, avoid taxes, avoid probate, mark charitable gifts, etc.)? B. In general, to whom do you want your estate to be distributed? C. Is there any reason to treat children (or grandchildren) other than equally? Page 13 of 15

14 D. History of Gifts: (1) Lists all gifts made in excess of $10,000 (or in excess of $3,000 if gift was made before 1982), (2) List all gifts of life insurance, and (3) List reason for making gift. Date of Gift Donor Donee Value Reason E. Have you ever filed a gift tax return? Yes No If yes, list years and attach a copy of all return. F. Do you have any expected inheritances from your parents or other relatives? Yes No If yes, list: Person from Whom You May Receive Something Relationship Age Estimated Value of Your Interest G. Describe any other contingent asset you are entitled to receive, i.e. negligence recovery, contract rights. Page 14 of 15

15 H. If you have ever been divorced, do you have any payable obligations either to your former spouse or to children of the prior marriage embodied in any court decree of written agreement? If so, please provide a copy of the documents. I. Did you acquire any of your property while a resident of any state other than Alabama? If so, list by state and property: J. Do you own any real property located outside of Alabama? If so, list by state and property: K. List any special requests regarding donation of body organs (eyes, kidneys, etc.) L. List any special requests regarding sustaining life by artificial support systems. M. Have you executed an Advance Directive for Health Care outlining your desires and appointing a proxy? If so, please attach a copy. N. Have you made provisions for managing you estate during disability (i.e. durable power of attorney)? If so, please attach a copy. Page 15 of 15