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1 ***You may complete this form electronically by filling in the Word Document, or print and complete by hand*** WEINER & McCULLOCH, PLLC ATTORNEYS & COUNSELORS AT LAW 5599 San Felipe Suite 900 Houston, Texas THOMAS W. MCCULLOCH, JD, CPA. PHONE: (713) FAX: (713) This data sheet helps us organize your information regarding your family and estate so that we are able to recommend and provide a beneficial estate plan. Please fill out as completely as possible and place question marks or X s on those items that seem inapplicable or about which you have questions/don t know the answer. For financial items, it is best to provide as much information as possible. If there is a number you believe might be incorrect, please write estimate next to the information. to Darby Gibbins: or Fax to: (713) Personal Information You Your Spouse Full Nickname or Preferred Birth Date: Date of Death (If applicable): Social Security Number: Occupation: Estimated Annual Income: Estimated Annual Investment Income: Work Telephone: Work Fax: Cell Phone: Address: Home Address (Include County): Home Telephone: Referred by: Military Service Information: (Branch, Date of Entry & Separation) Marital Status & Date and Place of Marriage (If applicable) If you have lived outside Texas during this marriage, please list the states and dates of residence: If either of you were previously married, list the dates of prior marriage, name or prior spouse, names of living children from prior marriage(s), and state whether marriage ended by death or divorce: Describe any real estate owned by either or both of you outside Texas: Single Widowed Married Divorced Page 1

2 Location of Safe Deposit Box: Name and Phone of Insurance Agent: Name and Phone of Accountant: Name and Phone of Broker/Financial Planner: Existing Estate Planning Documents: Trust (Type: ) Will Financial Power of Attorney Medical Power of Attorney Directive to Physicians HIPAA Authorization Declaration of Guardian Other: Children Trust (Type: ) Will Financial Power of Attorney Medical Power of Attorney Directive to Physicians HIPAA Authorization Declaration of Guardian Other: Full Name and Birthdate What is the current health status of you and your spouse? Any specific problems or concerns? Issues with capacity? You: _ Spouse: Is there anyone in your family with medical concerns or that requires special needs? Yes No Please Explain: What do you want us to help you accomplish? Address & Contact Information (If Child Does Not Reside With You) Is there anything else about you or your family or your personal goals that you would like us to know? Do you or your spouse have long term care insurance? You Spouse Both No Page 2 Other Occupation: Married: Yes No Student: Yes No Employed: Yes No Occupation: Married: Yes No Occupation: Married: Yes No

3 Assets Description Current Fair Market Value How Is Title Held?* Bank Accounts (not IRAs and Retirement Plans) Stocks, Bonds and Mutual Funds (not IRAs and Retirement Plans) Closely Held Businesses, Partnerships, Etc. Real Estate Automobiles, Boats, Etc. Other Property * If you know if the property is your separate property, your wife's separate property or community property, so state. If not, state the name(s) which appear on the title, if known, and state whether the property is held with right of survivorship, if known. If property is held in trust, please state the name of the specific trust. Page 3

4 Monthly Income Description/Source You Amount Spouse Wages Pension Social Security Investments Other Liabilities Description Amount Mortgages Other Liabilities Life Insurance and Annuities Company Insured Beneficiary(s) Face Amount Cash Value Page 4

5 IRAs, 401(k)s, and Other Retirement Plans Company/Custodian Participant Type of Plan Vested Amount Death Benefit Medical Expenses Description of Expense Spent For You or Spouse Amount of Expense Daily, Monthly or Annual Expense Health Insurance Medicare Supplemental Health Insurance Medicare or Private Care Agency or Facility Fees (IL, AL or SNF) Dispositive Plan: (Describe in general terms how you wish to leave your property at death) Page 5

6 Other Beneficiaries (Information about persons other than your spouse and descendants who you wish to benefit.) Full Name Age Address Relationship to You Fiduciaries (List name, address, home telephone and relationship to you for each person) You Your Spouse Executor: (The executor is the person responsible for probating the will, filing the estate tax return, and distributing assets to beneficiaries.) First Alternate Executor: Second Alternate Executor: Trustee: (The trustee is the person responsible for long-term management of property for the surviving spouse, children, or other beneficiaries.) First Alternate Trustee: Second Alternate Trustee: Guardian of Minor Children: (The guardian is the person who will take physical care of minor children should both parents die.) First Alternate Guardian: Second Alternate Guardian: Page 6

7 Guardian of Self: (This is the person who will take physical care of you should you become incapacitated.) First Alternate Guardian: Second Alternate Guardian: Guardian of Estate: (This is the person who will take care of your estate should you become incapacitated.) First Alternate Guardian: Second Alternate Guardian: Durable (Financial) Power of Attorney - Agent: (The property agent is the person who will handle your financial affairs if you become incapacitated.) First Alternate: Second Alternate: Health Care/Medical Power of Attorney Agent: (The health care agent is the person who will make medical decisions for you if you become incapacitated.) First Alternate: Second Alternate: Have there been any uncompensated transfers of property in the last 60 months? Yes No If yes, please list: Additional Information/Notes/Questions/Concerns: Page 7

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