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Tom A. Hemry, P.C.

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ESTATE PLANNING
CLIENT INFORMATION WORKSHEET

Although I would like to help everyone accomplish an estate plan, I can't accept everyone as a client who fills out a form. If I can't help you, I will respond quickly, and let you know about other attorneys that might be able to help you achieve what you want. I encourage you to be open to the best in yourself as you prepare this information, since a good plan is a reflection of you at your best.

The purpose of these questions is to help prepare you for an upcoming estate planning consultation. Completing the worksheet is time well spent, since it allows us to spend more time during your consultation discussion on the important details of your situation. If you feel uncomfortable answering these questions online, please feel free to print out the answers and send them directly to my office. Before we meet, I will need time to review these questions so that I can do an excellent job of meeting your needs and setting things up so that you can accomplish your goals and objectives. When I receive all of your information, I will call to schedule an appointment for you and your spouse. We will explore the estate planning that fits your situation in depth.

FAMILY INFORMATION
FIRST, I HAVE TO ASK ABOUT YOUR FAMILY, THE PEOPLE THAT YOU LOVE.

Please use the form below to request information. The highlighted fields with an asterisk (*) are required.

You
Full Name*:                                                       
Signature Name:                                         
Birth Date:                                                        
Employer:                                            
Occupation:                                         
Business Phone: 
Additional Information:                                      

Your Spouse:
Full Name:                                                          
Signature Name:                                        
Birth Date:                                                        
Employer:                                              
Occupation:                                   
Business Phone:                                           
Home Phone:     
Date of Death (if applicable):                                     

Address:        
City*:          
State*:          Zip: 
E-mail*:

(fill in if applicable)	You	Spouse
Previously Married?
Date of Divorce?
Widowed?

Date of Current Marriage:

Children:

Full Name	Parents	Birth Date	Marital Status

Other Dependents:

Full Name	Birth Date	Marital Status

Advisors:
Accountant: Phone:
Financial Advisor/Stockbroker: Phone:
Insurance Agent: Phone:

FINANCIAL INFORMATION
I NEED TO KNOW ABOUT WHAT YOU OWN SO THAT I CAN HELP YOU PLAN FOR DISPOSITION OF YOUR PROPERTY. EVERY KIND OF PROPERTY HAS DIFFERENT RESTRICTIONS AND USES IN ESTATE PLANNING, AND THE MORE I KNOW THE BETTER I CAN DESIGN A SOLUTION FOR YOU.
Real Property:

Address:	Owner:	Value:	Mortgage:

Motor Vehicles:

Make/Year	Owner:	Value:

Savings Accounts:

Bank:	Owner of account:	Account No.	Amount

Checking Accounts:

Bank:	Owner of account:	Account No.	Amount

Retirement Accounts & Pensions:

Institution:	Account No.	Value:	Beneficiary	Owner

Additional Information:
Brokerage Accounts:

Institution:	Owner:	Account No.	Value

Stock/Certificates in Your Possession:

Company	Owner:	No. Shares	Value/Share	Basis

Additional Information:
Insurance Policies:

Company:         
Policy No.:      
Insured:         
Cash Value:      
Death Benefit:   
Beneficiary:     
Owner:           
Loans on policy: 
Type of policy:  
Who pays?

Company:         
Policy No.:      
Insured:         
Cash Value:      
Death Benefit:   
Beneficiary:     
Owner:           
Loans on policy: 
Type of policy:  
Who pays?

Company:         
Policy No.:      
Insured:         
Cash Value:      
Death Benefit:   
Beneficiary:     
Owner:           
Loans on policy: 
Type of policy:  
Who pays?

Company:         
Policy No.:      
Insured:         
Cash Value:      
Death Benefit:   
Beneficiary:     
Owner:           
Loans on policy: 
Type of policy:  
Who pays?

Business Interests:

Name of Business	Owner:	Type of Business	Value

Personal Property & Other Assets of unusual value

Description	Owner:	Value

Income/Savings
Approximate Gross Income per year:
Approximate Amount Saved/Invested each year:

Important Questions:
Have either you or your spouse ever had a will or trust? Yes No
Is either you or your spouse not a U.S. citizen? Yes No
Does any family member have special needs that you care for? Yes No
Have you or your spouse ever signed a pre- or post- marital agreement? Yes No
Do you or your spouse have children from a previous marriage? Yes No
Did you or your spouse have substantial assets before you were married? Yes No
Are you supporting your adult children? Yes No
Are you making payments pursuant to a divorce agreement? Yes No
Do you have patents copyrights, or trademarks that are valuable? Yes No
Is there a shareholder agreement or buy-sell agreement on a business you own? Yes No
Does an IRA or pension plan regularly send you statements? Yes No
Have you or your spouse ever filed a gift tax return? Yes No
Do you own or operate a family business? Yes No
Are there charities or causes you would like to support? Yes No

All answers will be kept confidential and used by my office only for your estate planning purposes.

If you have answered Yes to any of these questions, or have any special concerns, please provide any details that would help me to understand your situation. Please send me documents that pertain to these questions through the mail.

Send all other information to:

TOM A. HEMRY, P.C.
Attorney At Law

P.O. Box 2118
Littleton, CO 80161

Telephone 303-221-1924
Facsimile 720-528-7675

ESTATE PLANNING CLIENT INFORMATION WORKSHEET