Date:  ______________________                                                                               

  Referred by:_______________________________

Name:  ___________________________________________________________________________________________________

Address: __________________________________________________________________________________________________

Phone:    Home____________________     Work____________________         Cell__________________               Fax_________

Occupation:______________________________________       Resided in Florida since _____                    Age_________

Have you ever made a will or a trust?______________         Safe deposit box is at__________________________ Bank

(If so, please bring it in)

Citizen of U.S. ___; Other:_________                                                 Accountant:_______________________________________

Life Insurance Agent:_________________________________   Stock Broker: _____________________________________

FAMILY INFORMATION                 Name                                      Address                                                 Phone                     Age

Spouse

Children

Spouse's Children

Parents

Spouse's Parents

Brothers & Sisters

Spouse's Brothers

  & Sisters

Persons Not Listed Above

  To Whom You Want To Leave   Something

                                                            NOTE:  We will discuss all of the following questions in more detail.

                                                                                   Please answer as best as you can for now.

REPRESENTATIVE INFORMATION

(Please list who you would want to serve in the following cases.  Please include alternates to serve in case the one you name does not.)

In case of your incapacity, who would you want to take care of your...

   - Financial decisions and bill paying:

   - Health decisions:

At your death, who do you want to take care of...

   - Administering your estate (personal representative):

   - Your minor children's financial affairs (guardian of property):

   - Your minor children's medical/personal decisions (guardian of person):

ASSET INFORMATION

(Just estimated values)                                       Your Name Alone              Joint with Spouse     Spouse's Name Alone

Life Insurance                                                       $                                                $                                                 $

Home

Other Real Estate

Stocks, Bonds, Etc.

Bank, Savings, CD's,

  Money Markets, Etc.

IRA's, Pensions, Etc.

Furnishings, Jewelry,

  Autos, & Tangible Property

Inheritances Expected

Other Assets

Totals

WILL AND TRUST DISPOSITIVE INFORMATION

(Please list to whom you want to leave your assets at your death.  Please list alternates to receive each gift in case the person you name dies before you.)

Special gifts of jewelry, furnishings, autos, collections and other tangible property:

(Please state whether the cost of delivery should be paid by the estate or by the beneficiary)

Gift of all remaining tangible property:

Special gifts of cash, stock or other specific items:

Gift of all remaining assets (residue):

ESTATE TAXES      (Generally, there is no federal estate tax for assets less than $675,000)

From whose share of the will do you want estate taxes paid?

                ________  Each gift pays its own share.

                ________  All taxes are paid from the residue.

                ________  Other:_________________________________________________________

Who do you want to pay estate taxes on property passing outside probate (not under the will)?

                ________  The person who receives the property.

                ________  The residue of the will.

                ________  Other:__________________________________________________________

TRUSTS FOR MINORS OR OTHERS

List anyone (such as minor children) for whom you want assets held in trust instead of being distributed to them at your death, so that the trustee invests and distributes the assets on a certain schedule until the beneficiaries can do so alone?

Who do you want to be the trustee (may be bank or individual)? 

   (Please list alternates)

List at what age you want the beneficiary to begin directly receiving income from the trust (e.g, age 21):

List at what age(s) you want the beneficiary to receive the principal (e.g., in thirds at ages 25, 30 and 35):

ESTATE PLANNING DOCUMENTS

In addition to discussing your last will and testament...

                Do you want to discuss the effect of holding assets in joint names or "in trust for" with others?

                                ______ Yes          ______ No

                Do you want to discuss setting up a living trust?

                                ______ Yes          ______ No

                Do you want to discuss giving someone your durable power of attorney to handle your financial affairs and bill paying?

                                ______ Yes          ______ No

                Do you want to discuss signing a living will to express your desires concerning the use or non-use of medical procedures to prolong your life in case of terminal illness?

                                ______ Yes          ______ No

                Do you want to discuss signing a designation of health care surrogate to give someone power to make medical decisions for you if you are unable to do so?

                                ______ Yes          ______ No

                Do you want to discuss signing a declaration of preneed guardian in case a court finds you or your minor child incapacitated?

                                ______ Yes          ______ No

                Do you want to discuss anything else?  Please list: