1 Personal Info
2 Residence & Capacity
3 Family Members
4 Advisors
5 Concerns
6 Background & History
7 Financial Info
8 Review & Sign
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Part I

Personal Information

All information provided is strictly confidential and will be used solely to design your estate plan.

Note: One individual should complete questions for both "Client" & "Spouse." If completing without your spouse present, leave spouse's personal concern fields blank.

Client Information

Primary

Marital Status

Required

Additional Information

Are you or your spouse receiving Social Security, disability, or other government benefits?
Do you or your spouse own real estate?
Do you or your spouse have an existing Will or Living Trust?
Step 1 of 8
Part I — Continued

Residence & Capacity

Primary Residence

Reverse Annuity Mortgage (RAM)?
Capital gains tax exclusion used?
Senior citizen property tax exemption used?
Veteran real property tax exemption used?

Capacity Assessment

Elder Law Screening
Are there any known problems with memory or understanding?
Client
Capacity Question
Able to sign name?
Able to speak?
Able to recognize friends & family?
Cognizant of property & possessions?
Able to leave current residence?
Are receiving long-term care?
Are currently in the hospital?
Is long-term care placement expected?
Step 2 of 8
Part I — Continued

Children & Other Family Members

Use full legal names. Indicate relationship code: JT = both spouses are parents, 1 = client's child, 2 = spouse's child, S = single parent.

Step 3 of 8
Part I — Continued

Professional Advisors

Please list any current advisors so we can coordinate your estate plan appropriately. Click "Add Advisor" for each one.

Your Advisory Team

Optional — add as many as apply
Step 4 of 8
Part I — Continued

Estate Planning Concerns

Rate each concern: H = High, S = Some, L = Low, N/A = Not applicable.

Level of Concern

DescriptionClient
Desire to get affairs in order and create a comprehensive plan to manage affairs in case of death or disability
Providing for and protecting a spouse
Providing for and protecting children
Providing for and protecting grandchildren
Disinheriting a family member
Providing for charities at the time of death
Plan for the transfer and survival of a family business
Avoiding or reducing estate taxes
Avoiding probate
Reduce administration costs at time of death
Avoiding a conservatorship ("living probate") in case of disability
Avoiding will contests or other disputes upon death
Protecting assets from lawsuits or creditors
Preserving privacy of affairs in case of disability or at time of death
Plan for a child with disabilities or special needs
Protecting children's inheritance from the possibility of failed marriages
Protect children's inheritance if surviving spouse remarried
Ensure death shall not be unnecessarily prolonged by artificial means
Step 5 of 8
Part I — Continued

Background & History

Help us understand your prior planning, legal history, and any circumstances relevant to designing your estate plan.

Please answer Yes or No for each question

Are you receiving Social Security, disability, or other governmental benefits?
Are you making payments pursuant to a divorce or property settlement order? (Please provide a copy)
Have you been widowed? (If a federal estate tax return was filed, please provide a copy)
Have you ever filed federal or state gift tax returns? (Please provide copies)
Have you completed previous will, trust, or estate planning? (Please provide copies)
Do you support any charitable organizations now that you wish to make provisions for at death?
Are there other charitable organizations you wish to make provisions for at death?
Are you currently a beneficiary of anyone else's trust?
Do any of your children have special educational, medical, or physical needs?
Do any of your children receive governmental support or benefits?
Do you provide primary financial support to adult children or others?
Step 6 of 8
Part II

Financial Information

List all property you own and its approximate value. Leave any section blank if not applicable. Use ownership codes: C = Client alone, S = Spouse alone, JTS = Joint with spouse, JTO = Joint with other, ? = Unknown.

Real Property

Homes, land, timeshares

Bank Accounts

CA · SA · CD · MM — No IRAs/401(k)s here

Retirement Benefit Accounts

401(k) · IRA · Profit Sharing · Thrift

Brokerage & Investment Accounts

Taxable investment accounts
Include taxable brokerage accounts holding stocks, bonds, mutual funds, or ETFs. Do not include IRAs or 401(k)s here — those go in Retirement Accounts above.

Life Insurance & Annuities

Personal Effects, Vehicles & Valuables

Major items only

Stocks & Bonds

Individual holdings

Business Interests

Partnerships, corps, sole props

Other Financial Items

Money Owed To You

Exempt Assets

Do you have a burial plot?
Client
Do you have an irrevocable burial fund contract?
Client
Step 7 of 8
Final Step

Review & Disclosure

Please review the disclosure statement below before signing and submitting your worksheet.

Disclosure & Reliance Statement

The information contained in this Worksheet fairly and fully:

  • Discloses all information about family, children, grandchildren, and heirs;
  • Discloses all assets owned by the undersigned, or in which the undersigned have any form of ownership interests;
  • Discloses the value of all such assets or ownership interests;
  • Discloses how these assets or ownership interests are owned; and
  • Has been prepared by, or at the direction of, or with the permission of the undersigned.

We certify that the information is accurate, correct, and complete and may be relied upon by Attorney Angelo P. Politakis in making estate planning recommendations. It is agreed and understood that if any of this information is incorrect or incomplete it may adversely affect his recommendations.

Sign above
Step 8 of 8

Worksheet Submitted

Thank you. Your estate planning worksheet has been received. Attorney Politakis will review your information prior to your consultation.

Questions? Call 219.220.4041 or email info@politakislaw.com