Personal Wealth Planning Data

and

Financial Inventory Worksheet

CLIENT
Name:____________________________________________________________
Address:__________________________________________________________
_____________________________ Phone:______________________________
Occupation:________________________________________________________
Business Address:___________________________________________________
_____________________________ Phone:______________________________
Date of Birth:_______________ Social Security No.:________________________


SPOUSE
Name:____________________________________________________________
Address:_________________________________________________________
_____________________________ Phone:____________________________
Occupation:______________________________________________________
Business Address:________________________________________________
_____________________________ Phone:____________________________
Date of Birth:_______________ Social Security No.:______________


CHILDREN
Child's Name:____________________________________________________
Address:_________________________________________________________
_____________________________ Phone:____________________________
Occupation:______________________________________________________
Business Address:________________________________________________
_____________________________ Phone:____________________________
Date of Birth:_______________ Social Security No.:______________
Spouse's Name:_______________ Occupation:_______________________
Names and ages of child's children:
_____________________________________________ Age:______________
_____________________________________________ Age:______________
_____________________________________________ Age:______________
_____________________________________________ Age:______________
_____________________________________________ Age:______________

Child's Name:____________________________________________________
Address:_________________________________________________________
_____________________________ Phone:____________________________
Occupation:______________________________________________________
Business Address:________________________________________________
_____________________________ Phone:____________________________
Date of Birth:_______________ Social Security No.:______________
Spouse's Name:_______________ Occupation:_______________________
Names and ages of child's children:
_____________________________________________ Age:______________
_____________________________________________ Age:______________
_____________________________________________ Age:______________
_____________________________________________ Age:______________
_____________________________________________ Age:______________


Child's Name:____________________________________________________
Address:_________________________________________________________
_____________________________ Phone:____________________________
Occupation:______________________________________________________
Business Address:________________________________________________
_____________________________ Phone:____________________________
Date of Birth:_______________ Social Security No.:______________
Spouse's Name:_______________ Occupation:_______________________
Names and ages of child's children:
_____________________________________________ Age:______________
_____________________________________________ Age:______________
_____________________________________________ Age:______________
_____________________________________________ Age:______________
_____________________________________________ Age:______________



Child's Name:____________________________________________________
Address:_________________________________________________________
_____________________________ Phone:____________________________
Occupation:______________________________________________________
Business Address:________________________________________________
_____________________________ Phone:____________________________
Date of Birth:_______________ Social Security No.:______________
Spouse's Name:_______________ Occupation:_______________________
Names and ages of child's children:
_____________________________________________ Age:______________
_____________________________________________ Age:______________
_____________________________________________ Age:______________
_____________________________________________ Age:______________
_____________________________________________ Age:______________
PARENTS
1. Client's Parents:
Father Mother
Name:________________________ _____________________________
Address:_____________________ _____________________________
_____________________________ _____________________________
Phone:_______________________ _____________________________


2. Client's Spouse's Parents:
Father Mother
Name:________________________ _____________________________
Address:_____________________ _____________________________
_____________________________ _____________________________
Phone:_______________________ _____________________________




OTHER DEPENDENTS
Give name, address, age, relationship, and annual cost of support.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________


MISCELLANEOUS INFORMATION
Are you a citizen of the United States? Yes ___________No ________
Is your spouse a citizen of the United States? Yes _______No _____
Do you presently have a will? Yes _____________No ________________
Do you presently have a trust? Yes ____________No ________________
Are any children or grandchildren adopted? Yes ________ No _______
Do you and your spouse have a pre-nuptial agreement? Yes ___No ___
Have you and your spouse ever lived in any of the following states: Arizona, California, Idaho, Louisiana, New Mexico, Nevada, Puerto Rico, Texas, or Washington? Yes _____________ No _______________
Describe any significant health problems you, your spouse or anyone depending on you for support may have:____________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
If you have minor children living when you die, whom do you want to raise them and be their guardian?
First Choice:
Name _______________________ Relationship _____________
Address ________________________________________________

Second Choice:
Name _______________________ Relationship _____________
Address ________________________________________________

You will need to appoint a separate guardian for your minor children's assets. If the person named above lives in the Commonwealth of Virginia, he or she will also serve as guardian of the children's assets. If not, you must name a separate individual who does live within the Commonwealth of Virginia. If this applies to your situation, whom do you wish to appoint?
First Choice:
Name _______________________ Relationship _____________
Address ________________________________________________
Second Choice:
Name _______________________ Relationship _____________
Address ________________________________________________

Should you decide to have a will, and not a trust, you will want to appoint an Executor to manage your estate upon your death. The person you choose will be responsible for gathering in the assets of the estate, paying debts, taxes and expenses, liquidating assets as required, distributing money and assets as directed, and settling the estate.

Whom do you desire to serve as Executor of your will?
__________________________________________________________________
What is his/her relationship to you? _____________________________
Whom does your spouse (if applicable) desire to serve as Executor of his/her will?________________________________________________
Relationship to Spouse __________________________________________

The executor you name may be unable or unwilling to serve when the time comes to accept the appointment, and, if accepting, there may come a time when he or she may be unable or unwilling to continue to serve. Therefore, you should provide for a successor or alternate Executor.
In the event the person you choose to serve as your Executor becomes unable or is unwilling to serve, whom do you want to serve as your succesor or alternate Executor?___________________________
What is his/her relationship to you? _____________________________
Spouse's Substitute Executor (If applicable) _____________________
Relationship to spouse ___________________________________________

DISTRIBUTIONS TO BENEFICIARIES AFTER YOUR DEATH
If you have children: Do you want them to receive their inheritance in lump sum at age ____, or in installments at the following specified ages ___________________________________________________

If one of your children dies before you: Does that child's inheritance go (1) ____ to his/her children, or (2) ____ to your other living children?

Do you wish to make any special gifts of property or cash to any individuals? Yes _______ No _______

Do you wish to make any gifts to your church or other charitable organizations? Yes ______ No ______
If so, is the gift to be effective at (1) ____ your death, (2)____ you and your spouse's death, (3) ____ minor child attaining the age of ____ years, or (4) ____ other (specify)?
If making a charitable gift, provide the exact name of the organization, address, and percent or dollar amount of gift.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Are there any relatives whom you specifically do not want to receive anything from your estate? Yes _____________ No ________

Are there any debts that you wish to forgive? Yes _____ No _____
After all special gifts have been distributed, whom do you want to receive the rest of your estate?
Name _________________ Relationship _______ Percentage _____
Name _________________ Relationship _______ Percentage _____
Name _________________ Relationship _______ Percentage _____
Name _________________ Relationship _______ Percentage _____

TRUST INFORMATION
Many people wish to use a trust to enable them to manage their assets during their lifetime and at the same time provide for their spouses', children's, and grandchildren's inheritance, but at the same time want to avoid probate. A revocable living trust will enable this objective to be met. Do you desire to establish a revocable living trust? Yes _____ No _____

If you desire to establish a trust, you must appoint a trustee to manage the trust. You will be the initial trustee of your revocable living trust unless you state otherwise.

In the event that you are not able to manage your trust due to death or disability, a successor trustee must be appointed. The successor trustee may be your adult children, a trusted friend, a financial advisor, or a trust company. If you choose an individual, please designate a second choice should your first choice become unable or��F4��F4�f�F4�µF4��F4��F4L2��F4______ Relationship _____________
Address ________________________________________________
Second Choice:
Name _______________________ Relationship _____________
Address ________________________________________________

LIVING WILL
A living will enables you to express your desire to not have artificial life support provided to you in the event that you become terminally ill or injured with no hope for recovery, or suffer from an irreversible coma. Some people do desire however, that they continue to be artificially administered food and water.

Do you desire a living will? Yes ____________ No _______________
Do you desire artificially administered food and water if you are terminally ill or injured? Yes _____________ No _______________
Does your spouse desire a living will? Yes ________ No__________
Does your spouse desire artificially administered food and water if he/she is terminally ill or injured? Yes _________ No __________

HEALTH CARE POWER OF ATTORNEY
A health care power of attorney will allow you to appoint someone to make decisions for you concerning your health care in the event you are unable to do so yourself. These decisions however, will not be in conflict with your expressed desires in your living will.

Do you desire a health care power of attorney? Yes _____ No ____

Does your spouse desire a health care power of attorney?
Yes _____ No _____

If you desire a health care power of attorney you must have an agent. The agent you select must be an individual, not a trust company. Unless you state otherwise, your spouse (if you are married) will be your agent. It is also recommended that you appoint an additional person to serve as your agent in the event your first choice is either unwilling or unable to serve.

Whom do you desire to serve as your agent? _______________________
What is his/her relationship to you? _____________________________
Whom does your spouse desire to serve as his/her agent? _______________________
What is his/her relationship to your spouse? ____________________
In the event the person you choose to serve as your agent becomes unable or is unwilling to serve, whom do you want to serve as your substitute agent? ________________________________________________
What is his/her relationship to you? _____________________________
Spouse's Substitute Agent (If applicable) ________________________
Relationship to spouse ___________________________________________

ASSET MANAGEMENT POWER OF ATTORNEY
Due to advances in our society's medical knowledge and technology, death does not come suddenly or unexpectedly to many people. Though one may not be terminally ill or suffering under an irreversible coma, he or she may become disabled to the point where managing one's own financial affairs - filing income taxes, dealing with retirement plans and investments, bringing or defending lawsuits, etc. - may be overly burdensome or impossible.

When such a disability occurs, costly and time-consuming court procedures are usually necessary to appoint a guardian or conservator for handing such problems. An Asset Management Durable Power of Attorney allows you to appoint your own agent to handle such affairs should you become disabled and are no longer able to do so yourself. The agent will have this power however, only in the event you are disabled. Otherwise you retain all legal powers as you normally would.

Do you desire an asset management power of attorney?
Yes _____ No _____
Does your spouse desire an asset management power of attorney?
Yes _____ No _____
Whom do you desire to serve as your agent? _______________________
What is his/her relationship to you? _____________________________
Whom does your spouse desire to serve as his/her agent? _______________________
What is his/her relationship to your spouse? ____________________
In the event the person you choose to serve as your agent becomes unable or is unwilling to serve, whom do you want to serve as your substitute agent? ________________________________________________
What is his/her relationship to you? _____________________________
Spouse's Substitute Agent (If applicable) ________________________
Relationship to spouse ___________________________________________

FINANCIAL INFORMATION
ASSETS

Type Assets                                                    You Own        Spouse Owns              Joint Total

                        Cash

                        Personal Residence

                        Other Real Estate

                        Business Interests

                        Retirement Plans

IRAs

                        Annuities

                        Stocks

                        Bonds

                        Mutual Funds

                        Notes

                        Receivables

                        Automobiles

                        Collections

                        Other Personal Property

                        Other Assets

                        Total

Do you or your spouse expect to receive any additional cash or property from a gift, inheritance, lawsuit or other claim?
__________________________________________________________________

Please provide details concerning insurance policies on your life and on your spouse's life.
Insured Beneficiary Owner Death Benefit Type*
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
* W = Whole Life U = Universal T = Term G = Group

For those that need further assistence, The Law Offices of George Teitelbaum offer a wide variety of probate, estate and elder law services for clients throughout the District of Columbia and Maryland. For more information, please contact our law office today. Attorney George Teitelbaum also assists clients located out of state that may have legal issues in the District of Columbia. To go to his main web site Click here.