"ESTATE PLANNING / GUARDIANSHIP INTERVIEW FORM"

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: ___________________________________________

Today's 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.