SELF

  
Name:____________________________________ Date of Birth:____________________
Home Address:__________________________________
Telephone:____________________
Business Address:__________________________________
Telephone:____________________
Nature of Employment:________________________________
SS No.: ____________________
Date of Marriage:__________________________________ Previous Marriage: Yes____ No____
SPOUSE 
Name:____________________________________ Date of Birth:____________________
Home Address:__________________________________ Telephone:____________________
Business Address:__________________________________ Telephone:____________________
Nature of
Employment:________________________________		 SS No.: ____________________
Date of Marriage:__________________________________ Previous Marriage: Yes____ No____
CHILDREN 
1. Name:___________________________ Date of Birth:____________   SS#:______________
2. Name:___________________________

Date of Birth:____________   SS#:______________
3. Name:___________________________ Date of Birth:____________   SS#:______________
4. Name:___________________________ Date of Birth:____________   SS#:______________
Identify children (by #):____   Adopted:_____________   By Previous Marriage: (H)____________ (W)____________

FINANCIAL DATA

 
A. REAL ESTATE 
Description
 Fair Market Value
How Property Is Titled Owner (Name) and Form of Title: Joint Tenancy (JT) Tenancy in Common (TC) or Sole Owner
1. Home:___________________________ $______________ ______________________
2. ________________________________ $______________ ______________________
3. __________________________________ $______________ ______________________
TOTAL: $______________  

B. OIL AND GAS PROPERTIES

Description

Fair Market Value

How Property is Titled

1. __________________________________ $______________ ________________
2. __________________________________ $______________ ________________

TOTAL:

 $______________  

C. CASH

Bank

Average Balance

Type of Account

How Account is Titled
(Savings, Checking)

1._____________________ $_________________ ________________ ________________
2._____________________ $_________________ _________________ ________________
3._____________________ $_________________ _________________ ________________
4._____________________ $_________________ _________________ ________________

TOTAL:

 $_________________    

D.MONEY MARKET, T-BILLS, C.D.'S, ETC.

Issuer

Description of Instrument

Face Amount

How Property Is Titled

1._______________________ ___________________ $_____________ ______________________
2._______________________ ___________________ $_____________ ______________________
3._______________________ ___________________ $_____________ ______________________
4._______________________ ___________________ $_____________ ______________________

TOTAL:

 $_____________________    
E. SECURITIES

Issuer

Description (Stocks, Bonds, Mutual
Funds, Etc.)

Fair Market
Value

How Property Is Titled

1._______________________ _________________ $_____________ ________________________
2._______________________ _________________ $_____________ ________________________
3._______________________ _________________ $_____________ ________________________
4._______________________ _________________ $_____________ ________________________
 

TOTAL:

 $______________  
F. RETIREMENT ACCOUNTS

Type of Account
(I.R.A.'s, Pension, Profit sharing, SEP's, etc.)
Owner
Beneficiary
Current
Value
1. _________________________ ___________________ ______________ $__________
2. _________________________ ___________________ ______________ $__________
3. _________________________ ___________________ ______________ $__________
4. _________________________ ___________________ ______________ $__________
   

TOTAL:

 $___________

G.CARS, FURNITURE AND CLOTHING      

Fair Market Value

  $____________________
H.VALUABLE PERSONAL PROPERTY

Object

Fair Market Value

Owner

1.______________________________ $____________ ____________________
2.______________________________ $____________ ____________________
3.______________________________ $____________ ____________________
4.______________________________ $____________ ____________________

TOTAL:

 $_____________  
I.LIFE INSURANCE

Company - Policy #

Owner

Beneficiary

Face Amount

Loans

1._____________________ _________________ _________________ $___________ $___________
2._____________________ _________________ _________________ $___________ $___________
3._____________________ _________________ _________________ $___________ $___________
4._____________________ _________________ _________________ $___________ $___________
   

TOTAL:

 $____________ $____________
J.BUSINESS INTERESTS

Business:____________________  Address:__________________________ Nature of Business:______________________________________________ Type of Organization (Circle): C Corporation, S Corporation, Partnership, Limited Partnership, L.L.C., Trust or Sole Proprietorship Fair Market Value of Business: $ ______________________ Percent of Your Ownership: _________________% Attach copies of Stock Purchase or other Stock Agreements. (If you own interest in more than one business, repeat information on separate sheet)
K. ANNUAL INCOME

Husband:

Source:_______________

Source:_______________

Source:_______________

 

Amount: $______________

Amount: $______________

Amount: $______________

Wife:

Source:_______________

Source:_______________

Source:_______________
 

Amount: $______________

Amount: $______________

Amount: $______________

L. ASSETS NOT IDENTIFIED PREVIOUSLY

Description

Fair Market Value

How Property Is Titled

1.___________________________________ $_____________ _____________________
2.___________________________________ $_____________ _____________________
3.___________________________________ $_____________ _____________________
4.___________________________________ $_____________ _____________________

TOTAL:

 $_____________  
M. BENEFICIARY

Are you beneficiary, or possible beneficiary, of any:

1. Trust? If so, describe:

 

2. Life Insurance not identified in I? If so, describe:

 

3. Power of Appointment? Yes No. If yes, attach copy of instrument which grants power.

 

4. Estate? If so, describe:

 

5. Gift? If so, describe:



N.LOANS

Amount

Debtor

Creditor

Due Date

Terms

Security for Loan
(Identify by Asset i.e., A.1.)

1. $__________ ________________ ________________ _________ __________ ____________
2. $__________ ________________ ________________ _________ __________ ____________
3. $__________ ________________ ________________ _________ __________ ____________
$_________

TOTAL

        

O. OTHER OBLIGATIONS

Obligation
(Surety, Term Leases,
Guarantor, etc.)

Obligor

Terms

Security for Obligation
(Identify by Asset, i.e., A.1.)

1.____________________________ ____________ ___________________ ______________________
2.____________________________ ____________ ___________________ ______________________
3._____________________________ ____________ ___________________ ______________________
4.____________________________ ____________ ___________________ ______________________

P. TAXABLE GIFTS PREVIOUSLY MADE

To Whom

Property

Reported Value

Year of Gift

1.________________________ _________________________ $__________ 19_____
2.________________________ _________________________ $__________ 19_____

PLANNING GOALS AND OBJECTIVES

 

1. Describe how you wish your property to be distributed.

 

 

 

 

 

 

2. Any special health, education, etc., situations or circumstances in family you wish addressed?

 

 

 

3. Special provisions relating to husband.

 

 

 

4. Special provisions relating to wife.

 

 

 

5. Special provisions relating to others (children, parents, brothers, sisters, etc.).

 

 

 

6. Charitable gifts. To whom and amount or property.

 

 

7. Guardian for minor children:

Primary

Alternate

Name:__________________________

Name:__________________________

Address:__________________________

Address:__________________________

 

 

 

8. Do you wish to prepare a Directive to Physician (Living Will)? Yes No

 

 

 

9. Do you wish to appoint a Health Care Proxy? Name:

 

 

 

10. Do you wish to prepare a Durable Power of Attorney? Yes No

Who shall have the power?

 

 

 

11.BE SURE TO ATTACH COPY OF YOUR CURRENT WILL AND TRUST

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