ESTATE PLANNING AND WILL/TRUST INFORMATION FORM

DUDLEY AND SMITH, P.A.

2602 U.S. Bank Center

101 East Fifth Street

St. Paul, MN  55101

Tel: (651) 291-1717

Fax: (651) 223-5055

info@dudleyandsmith.com

 PLEASE PRINT, COMPLETE AND MAIL OR COPY, COMPLETE AND E-MAIL

Date:                                                    

 

LEGAL SERVICES PLAN MEMBERS ONLY.

 

1.  Plan Provider (Prudential, Hyatt, ARAG Group, Legal Services Plan, etc.)                                                 2.  Employer                                                                                                                                                                3.  Plan/Authorization Number                                                                                                                              

 

1.  TESTATOR/TESTATRIX

 

A. HUSBAND OR SINGLE PERSON

Name:                                                                                                                                                           

Address:                                                                                                                                                         

Phone Number:  Home                                                      Work                                                              

Date of Birth:                                                                                County of Residence __________________

Your Social Security #                                                                  U.S. Citizen?   Yes               No             

 

B. WIFE

Name:                                                                                                                                                            

Address:                                                                                                                                                       Phone Number:  Home                                                       Work                                                              

Date of Birth:                                                                     County of Residence ___________________

Your Social Security #                                                       U.S. Citizen?   Yes               No             

 

2. CHILDREN - please list all children.  If you do not plan to provide for a child in your will, the child must be specifically omitted by name.  (Use back or attach a separate page if more space is needed):

 

 Name                                                                                                                          Date of Birth                 Married Name              Address

 

 

 

 

 

 

 

A. Have any children received an advance on their inheritance or are any children financially indebted to you?               Yes             No     If so, how do you wish to address this matter in your will?                                                                                                                                                                                                  

 

B. Is there any reason to treat your children other than equally?           Yes             No     If so, how do you wish to address this matter in your will?                                                                                                        

C. Are any of the children spendthrifts?           Yes             No     If so, how do you wish to address this matter in your will?                                                                                                                                         

 

D. Are any of the children under a disability?           Yes             No     If so, how do you wish to address this matter in your will?                                                                                                                                         

 

E. Please indicate if you have been married previously.              Yes             No    (If so, please give any details on back you believe to be pertinent to the drafting of your will.)

 

3. If any child should predecease parent, should his/her share pass through to his/her children?                               

4. Who should be GUARDIAN of your minor children?  (A guardian has physical and/or legal control over your   children until they reach the age of 18).  The surviving spouse is automatically guardian unless otherwise              determined by the court.

 

A. First Choice:

Name(s)                                                                                                                                                                  Address:                                                                                                                                                                               ________________________________________________________________________

Telephone Number:                                                                                                                                                 Relationship (if any):                                                                                                                         

 

B. Alternate:

Name(s)                                                                                                                                                                  Address:                                                                                                                                                                                                                                                                                                                               

Telephone Number:                                                                                                                                                 Relationship (if any):                                                                                                                         

 

5.  If you want a TRUST or believe a trust may be necessary, please indicate who the trustee(s) should be.  (A trustee manages the assets for your children or other beneficiaries until they reach specified ages.  If you do not establish a trust, children inherit at age 18.  You may name an individual, bank or trust company or both.)

 

A. First choice: 

Name(s)                                                                                                                                                                  Address:                                                                                                                                                                                                                                                                                                                              

Telephone Number:                                                                                                                                                 Relationship:                                                                                                                                       

 

B. Alternate trustee: 

Name(s)                                                                                                                                                                  Address:                                                                                                                                                                                                                                                                                                                              

Telephone Number:                                                                                                                                                 Relationship:                                                                                                                                      

 

 

C. Terms of distribution (education, marriage, etc.)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

 

D. Age(s) for distribution to children from the trust (Ex. 1/2  @ age 25, 1/2 @ age 30)                                                                                                                                                                                                                                                                                                                                                                                  

 

6.  How should your estate be distributed if your spouse and/or children do not survive you or if you are not married  or if you do not have children. (Ex:  family, charity, etc.)                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

 

7.  Who should be PERSONAL REPRESENTATIVE ("executor") of your estate?  (A Personal Representative is responsible for probating your will, paying your debts, collecting your assets, and settling your estate.)

 

Husband/Single Person

 

A. First choice (Spouse is normally named first):                                                                                                     Address:                                                                                                                                                                                                                                                                                                                                   

Telephone Number:                                                                                                                                                 Relationship:                                                                                                                                                   

B. Alternate: Name                                                                                                                                                 Address:                                                                                                                                                                                                                                                                                                                                   

Telephone Number:                                                                                                                                                 Relationship:                                                                                                                                                 

 

C. Second Alternate:  Name                                                                                                                                    Address:                                                                                                                                                                                                                                                                                                                                   

Telephone Number:                                                                                                                                                 Relationship:                                                                                                                                                  

 

Wife

 

A. First choice (Spouse is normally named first):                                                                                                     Address:                                                                                                                                                                                                                                                                                                                                   

Telephone Number:                                                                                                                                                 Relationship:                                                                                                                                                 

 

B. Alternate: Name                                                                                                                                     Address:                                                                                                                                                                                                                                                                                                                                   

Telephone Number:                                                                                                                                                 Relationship:                                                                                                                                                          

C. Second Alternate:  Name                                                                                                                                    Address:                                                                                                                                                                                                                                                                                                                                    

Telephone Number:                                                                                                                                                 Relationship:                                                                                                                                                  

 

 

THE PURPOSE FOR THE FOLLOWING INFORMATION IS TO HELP DETERMINE THE PROPER WILL OR TRUST NECESSARY TO EFFECTIVELY PROTECT YOUR FINANCIAL AND OTHER INTERESTS.  PLEASE COMPLETE TO THE BEST OF YOUR KNOWLEDGE.  APPROXIMATE VALUES AND INFORMATION IS FINE.

 

8.  Do you own your home? ____ Yes   ____ No    If so, please indicate the following:

 

A. Names of all owners                                                                                                                                           B. Approximate "fair" market value of homestead (This may be higher than tax value.)$                                         C. Amount of any mortgage, contract for deed, etc.                                                                                       

 

9.  Do you own any other real estate?                            If so, please list the following:

 

A. Address/Legal Description:                                                                                                                                                                                                                                                                                                             

B . Approximate fair market value $                                                                                                              

C. Names of all owners:                                                                                                                                          D. Amount of any mortgage, contract for deed, etc.                                                                                                E. Your wishes for its disposition upon your death:                                                                                      

(If you have additional properties, please list on the back including the above requested information.)

 

10.  Bank accounts and deposits (Use back if more space is needed):

 

A. Checking: Name of Bank                                                                                                                       Owner(s)                                                                                                Average balance $                          

 

B. Savings: Name of Bank                                                                                                                          Owner(s)                                                                                                Average balance $                           

 

C. Savings: Name of Bank                                                                                                                          Owner(s)                                                                                                Average balance $                            

 

D. Money Market: Name of Fund                                                                                                               Owner(s)                                                                                                Average balance $                          

 

E. Mutual Fund: Name of Fund                                                                                                                   Owner(s)                                                                                                Average balance $                           

 

F. Individual Retirement Account: Name of Fund                                                                                        Owner                                                                                                    Average balance $                            

Beneficiary                                                                                                                                                       

G. Individual Retirement Account: Name of Fund                                                                                       Owner                                                                                                 Average balance $                       Beneficiary                                                                                                                                                      

 

11.  Life Insurance (Use back if more space is needed):

 

A. Name of Company and Policy number, if known                                                                                                 B. Insured/Owner                                                                                   Amount $                                       

C. Primary Beneficiary(ies)                                                                                                                                      D. Secondary Beneficiary(ies)                                                                                                                       

 

A. Name of Company and Policy number, if known                                                                                                 B. Insured/Owner                                                                                             Amount $                                       C. Primary Beneficiary(ies)                                                                                                                                      D. Secondary Beneficiary(ies)                                                                                                                       

 

A. Name of Company and Policy number, if known                                                                                                 B.  Insured/Owner                                                                                                 Amount $                                  C. Primary Beneficiary(ies)                                                                                                                                      D. Secondary Beneficiary(ies)                                                                                                                        

 

A. Name of Company and Policy number, if known                                                                                                 B. Insured/Owner                                                                                                Amount $                                    C. Primary Beneficiary(ies)                                                                                                                                      D. Secondary Beneficiary(ies)                                                                                                                        

 

12.  Securities, Stocks and Bonds (Use back if more space is needed):

 

A. Name of Company                                                                                                                                              B. Owner(s)                                                                                         Approximate Value $                        

A. Name of Company                                                                                                                                              B. Owner(s)                                                                                          Approximate Value $                       

 

13.  Are you entitled to any pension/profit-sharing proceedings?                  If so, please give approximate value:  $                          ;   Beneficiary Designation:                                                                                                           

 

14.  Personal Property - Describe and give a value of any items of substantial values,  such as automobiles, works of art, jewelry, etc.  Be sure to include any items listed on an insurance rider.

 

Description Approximate Value

 

 

 

 

15.  Do you wish to make any charitable bequests?             Yes             No     If so, to which charities do you wish to make bequests to?                                                                                                                                                   

 

16.  Do you have a safe deposit box?              If so, where?                                                                                      

 

17.  Do you expect any inheritance in the near future?                         If so, please give details:                                                                                                                                                                                                                    

 

18.  Do you have any other assets of any kind, such as business interest?             If so, please list:                                                                                                                                                                                                              

 

19.  Do you have any special requests regarding funeral or burial instructions or organ donation?  If so, please list the request here for including in your health care directive or will.  You may also wish to write a letter of instruction to your family or person who will be handling these matters for you.                                                                                                                                                                                                                                                             

 

20.  Please state specifically if you wish to be an organ donor.             Yes               No

 

21.  Is there any other provision that you would like made in your will(s) that has not been dealt with on this form?                                                                                                                                                                                                                                                                                                                                                                            

 

The documents in paragraphs 22 and 23 are highly recommended to avoid court costs, attorney fees and loss of time in the future.  There is an extra charge involved in preparing the documents mentioned, but it is nominal, especially  compared to future costs if they are needed.  (If you are under a legal services plan, these services may be covered.)

 

22.  Are you interested in preparing a Power of Attorney granting another person the power to act on your behalf to manage your assets and pay your bills if you become incompetent or unable to sign your name?        Yes         No  If so, please complete the following:

 

Husband/Single Person

 

ATTORNEY-IN-FACT (First Choice):

 

A.  Name:                                                                                                                                                               B.  Address:                                                                                                                                                                                                                                                                                                                              

C.  Phone Number:                                                                                                                                          

D.  Relationship:                                                                                                                                              

SUCCESSOR

 

A.  Name:                                                                                                                                                               B.  Address:                                                                                                                                                                                                                                                                                                                              

C.  Phone Number:                                                                                                                                                  D.  Relationship:                                                                                                                                             

Wife

 

ATTORNEY-IN-FACT (First Choice):

 

A.  Name:                                                                                                                                                               B.  Address:                                                                                                                                                                                                                                                                                                                              

C.  Phone Number:                                                                                                                                          

D.  Relationship:                                                                                                                                             

 

SUCCESSOR:

 

A.  Name:                                                                                                                                                               B.  Address:                                                                                                                                                                                                                                                                                                                               

C.  Phone Number:                                                                                                                                                  D.  Relationship:                                                                                                                                              

23.  Are you interested in preparing a Health Care Declaration ("living will") stating your preferences for health care if you are in a terminal condition?             Yes             No  If so, please indicate whom you would want your proxy to be:

 

Husband/Single Person

 

FIRST CHOICE:

 

A.  Name:                                                                                                                                                        

B.  Address:                                                                                                                                                                                                                                                                                                                                          

C.  Phone Number:                                                                                                                                        

D.  Relationship:                                                                                                                                            

 

SUCCESSOR:

 

A.  Name:                                                                                                                                                       

B.  Address:                                                                                                                                                                                                                                                                                                                                           

C.  Phone Number:                                                                                                                                          

D.  Relationship:                                                                                                                                             

 

Wife

 

FIRST CHOICE:

 

A.  Name:                                                                                                                                                      

B.  Address: