ESTATE PLANNING INFORMATION

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1 ESTATE PLANNING INFORMATION I PERSONAL AND FAMILY DATA A. Husband Husband's Name: (First) (Middle) (Last) Social Security Number Home Phone Employer Business Address Business Phone Place of Birth: U.S. Citizen (Yes or No) Home Fax Business Fax Date of Birth Position B. Other Family Members: 1. Husband's Father Mother a. Living? b. Name c. Age d. Address 1. Husband's brothers and sisters: Name Age Address Married? D. Wife: ESTATE PLANNING INFORMATION Page 1

2 Wife s Name: (First) (Middle) (Last) Social Security Number Home Phone Home Fax Has wife worked since marriage? Employer Position Business Address Business Phone Place of Birth: Business Fax Date of Birth U.S. Citizen (Yes or No) E. Other Family Members: 1. Wife s Father Mother a. Living? b. Name c. Age d. Address F. Wife s brothers and sisters: Name Age Address Married? G. Marriages ESTATE PLANNING INFORMATION Page 2

3 If either husband or wife has been married before, please furnish below the following information as to each prior marriage: (1) name of former spouse; (2) date and place of the marriage; (3) place, date and cause (death, divorce, etc.) of termination of the marriage. Also, it will be helpful for you to let us review copies of any agreements or judicial orders in connection with any prior divorce, and any marital property agreements or other similar documents relating to your present marriage. H. Children Please indicate whether adopted or by previous marriage, in addition to other data. 1. Name: SS# Age: Occupation: Child's Spouse: Name: SS# Age: Occupation: Child's Children: Name Address Age Occupation 2. Name: SS# ESTATE PLANNING INFORMATION Page 3

4 Age: Occupation: Child's Spouse: Name: SS# Age: Occupation: Child's Children: Name Address Age Occupation 3. Name: SS# Age: Occupation: Child's Spouse: Name: SS# Age: Occupation: Child's Children: Name Address Age Occupation [If there are additional children, please continue on the back of this page.] If there are any special circumstances with respect to any children or grandchildren (health status, special educational requirements, etc.), please so indicate: ESTATE PLANNING INFORMATION Page 4

5 I. Others Financially Dependent upon Husband or Wife: Name Address Relationship Occupation Comments Comments or unique family circumstances not indicated above: II DISPOSITION OF PROPERTY AND SELECTION OF REPRESENTATIVES A. Husband: In general, describe the way the husband wants his property to pass upon his death (use back page if necessary). 1. If wife survives husband: 2. If wife does not survive husband: 3. If neither wife nor children (grandchildren) survive husband: ESTATE PLANNING INFORMATION Page 5

6 4. Special provisions with respect to any specific properties? B. Selection of Husband's Representatives: List below the name, age, relationship and address of the person (or the name and address of the Bank) that husband wishes to have serve in the capacities indicated: 1. Executor: 2. Alternate Executor(s): 3. Trustee: 4. Successor Trustee: 5. Guardian: 6. Alternate Guardian: C. Wife: In general, describe the way the wife wants her property to pass upon his death (use back page if necessary). 1. If husband survives wife: 2. If husband does not survive wife: 3. If neither husband nor children (grandchildren) survive wife: ESTATE PLANNING INFORMATION Page 6

7 4. Special provisions with respect to any specific properties? D. Selection of Wife's Representatives: List below the name, age, relationship and address of the person (or the name and address of the Bank) that wife wishes to have serve in the capacities indicated: 1. Executor: 2. Alternate Executor(s): 3. Trustee: 4. Successor Trustee: 5. Guardian: 6. Alternate Guardian: E. If either husband or wife has a will presently in existence, please indicate date and location. In addition, it would be helpful for us to be able to review copies, if they are available. F. If either husband or wife has selected a bank to serve as executor or trustee, may we provide the bank a copy of this form? ESTATE PLANNING INFORMATION Page 7

8 III FINANCIAL DATA On the reverse side of this page, please indicate (1) whether any assets were owned by either spouse before marriage or acquired thereafter by gift or inheritance, and (2) the manner in which bank accounts, deposit certificates and securities are registered. A. Assets Approximate Value 1. Average cash balance (including savings, (certificates of deposit, etc) 2. Securities (stocks,bonds,mutual funds, etc.) 3. Business interests (describe) 4. Residence Value (Deed Description) Less Mortgage Real Equity 5. Other Real Estate (Describe) (Describe) (Describe) Value Less Mortgage Real Equity Value Less Mortgage Real Equity Value Less Mortgage Real Equity 6. Autos, Boats or Planes: 7. Livestock: ESTATE PLANNING INFORMATION Page 8

9 8. Other assets, including unusually valuable household furnishings, etc. 8. Life insurance on life of husband: Insurance Company Policy # Face Amount Date of Issue Present Beneficiary Primary Contingent Accidental Death ESTATE PLANNING INFORMATION Page 9

10 9. Life insurance on life of wife: Insurance Company Policy # Face Amount Date of Issue Present Beneficiary Primary Contingent Accidental Death If any life insurance policy listed above is owned by someone other than insured (spouse, business, etc.), please indicate by asterisk (*) and provide details below: 10. Employment Benefits: Please indicate in left column whether by reason of husband's employment (H) or wife's employment (w). On the reverse side of this page, please indicate the beneficiary who has been named to receive any death benefits from any such plan, and the manner in which such payments are to be made (i.e., lump sum, annuity, etc.) Pension Plan Thrift Plan Profit-Sharing Plan Other (describe) such as government disability, retirement pay, teacher's retirement, stock options, etc. ESTATE PLANNING INFORMATION Page 10

11 11. Inheritances: If either husband or wife owns any inherited property not previously listed, or expects to inherit any property, please give general description, source and approximate value. 12. Beneficial Interests: If either husband or wife is a beneficiary of any trust, or has any power or trusteeship position with respect to any trust, or has any estate in property for life, please give a general description of circumstances and approximate value. 13. Other business interests: (Partnerships, proprietorships, closely held corporations) Please supply general information relating to ownership, nature and value of business and any plans or arrangements relating to disposition of the interest of a deceased owner. 14. Gifts: If either husband or wife has at any time made gifts other than customary Christmas, birthday or holiday gifts, and if such gifts were in significant amounts (in excess of 1,000, for example), please indicate the dates, recipients and values of such gifts, the general nature of the gift property, and whether husband or wife filed any United States gift tax returns in connection with such gifts. ESTATE PLANNING INFORMATION Page 11

12 NOTES S:\WLW\JOY Personal\MEMOS\Ex\ESTATE PLANNING\QUESTIONNAIRE-FEB2000.wpd ESTATE PLANNING INFORMATION Page 12

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