Client Asset Information

______’S JOURNEY TO ESTATE PLANNING PEACE OF MIND

ASSET BOOK

Page 1

Real Property Interests

Please list all interests that you own directly in real property. This includes your home(s), any investment properties (e.g. rental properties), and land.

For each listed property please provide:

a copy of your most recent property tax bill
a clear copy of the most recent recorded Grant Deed or equivalent deed (i.e. Quit Claim, Corporate, Inter-spousal, Gift)

CAUTION: Deeds of Trust or Reconveyance are not acceptable!

PLEASE NOTE: A key component of the deed is the legal description of the property. This may be either on the front page of the deed or attached as “Exhibit A” or “Exhibit One”. Please make sure that the deed you are submitting includes the legal description.

If you cannot locate the deed(s), please contact our office. We can usually obtain copies of the required deed(s), a modest search fee may apply.

(For any Real Property interests owned inside a formal partnership, simply list the Partnership above under the Partnership & Business Interests section).

Property Address

/ /

How Owned[1]

/ /

Loans

/ /

Approx. Value

1.

/ / / / / /

$

2.

/ / / / / /

$

3.

/ / / / / /

$

4.

/ / / / / /

$

5.

/ / / / / /

Cash Accounts

Please complete the information on these sheets.

PLEASE DO NOT submit copies of your account statements as a substitute for completing this form.
Please provide an approximate monthly balance/value.
Balances/values are optional but recommended.

Banking Institution

/ /

Account Number

(Partial account number is OK) / /

Balance

Checking Accounts[2]:

/ / / /
/ / / /

$

/ / / /

$

/ / / /

$

/ / / /

$

Savings Accounts:

/ / / /
/ / / /

$

/ / / /

$

/ / / /

Money Market Accounts:

/ / / /
/ / / /

/ / / /

Certificates of Deposit:

/ / / /
/ / / /

/ / / /

Investment Securities

Brokerage Accounts:

Please list all accounts held with brokerage firms, these accounts may hold stocks, bonds, mutual funds, money market accounts or CDs for you.

PLEASE DO NOT list Retirement Accounts here, e.g. IRAs, 401Ks, etc.

Brokerage Firm:

/ /

Account Number

(Partial account number is OK) / /

Balance

/ / / /

Stocks:

Please list all stock in publicly-traded corporations (NYSE, AMEX, NASDAQ) that you hold DIRECTLY, i.e. NOT through a brokerage or retirement account. Stock in family or non-publicly-traded companies should be listed in the Business Interests section.

Stock Name:

/ /

Number of Shares:

/ /

Value

/ / / /

Stock Options:

Please summarize the approximate Current Value of any Stock Options that either of you hold (vested or not).

You should also ascertain whether these may be assigned to the Trust (most cannot).

Company Name:

/ /

Number of Options:

/ /

Value

/ / / /

Dividend Reinvestment:

Please list all accounts in corporations in which you hold stock in dividend reinvestment accounts.

Company Name:

/ /

Account Number

/ /

Value

/ / / /

Mutual Funds:
Please list all Mutual Funds that you hold DIRECTLY, i.e. NOT through a brokerage or retirement account.

Fund Name:

/ /

Account Number

/ /

Value

/ / / /

Corporate and Municipal Bonds:

Please list all Bonds that you hold DIRECTLY, i.e. NOT through a brokerage or retirement account.

Bond Name:

/ /

Account Number

/ /

Value

/ / / /

U.S. Savings Bonds:

Please list a SUMMARY of any U.S. Savings Bonds you own. We do not need the exact details

Type of Bond:

/ /

Number of Bonds:

/ /

Value

/ / / /

U.S. Treasury Direct:

Account Name:

/ /

Account Number

/ /

Value

/ / / /

Life Insurance

Life Insurance:

Partner A: Number of Life Insurance Policies:

/ / /

Face Amount:

/ / /

Cash Value:

Partner B: Number of Life Insurance Policies:

/ / /

Face Amount:

/ / /

Cash Value:

Retirement Plans

Investment Retirement Accounts (IRAs):

Partner A: Number of IRAs:

/ / /

Value:

Partner B: Number of IRAs:

/ / /

Value:

Qualified Plans (Pension Plans, 401k, Keogh, 403b, 457):

Partner A: Number of Qualified Plans:

/ / /

Value:

Partner B: Number of Qualified Plans:

/ / /

Value:

Annuities:

Partner A: Number of Annuities:

/ / /

Value:

Partner B: Number of Annuities:

/ / /

Value:

Safe Deposit Box

Safe Deposit Boxes:

Bank name / Bank address / Box #

Miscellaneous Assets

Personal Property:

Please list here all valuable art, jewelry, furniture, collections or other personal items with an individual value exceeding $5,000. Please do NOT list Cars, Boats, Airplanes and Vehicles here.

Property Description

Appraisal[3]

/ /

Approx. ValueValue

/ /

Transferable Memberships:

Please list all memberships that have monetary value and permit your interest to be transferred.

Description:

/ /

Value

/ /

Burial Plots:

Please list all burial plots or contracts with cemeteries for burial.
Name and Address of Burial Plot Location address / Value
$
$

Partnership & Business Interests

Please indicate if any of these are Licensed Professions (LP).

General Partnerships:

Are any of these Licensed Professions (LP)?

Partnership Name

/ /

General Partner

/ /

Licensed Profession

/ /

Value

/ /

/ / / /

/ /

/ / / /

Limited Partnerships:

Are any of these Licensed Professions (LP)?

Partnership Name

/ /

General Partner

/ /

Limited Partner

/ /

Licensed Profession

/ /

Value

/ /

/ / / /

/ /

/ / / /

Limited Liability Companies LLPs:

Are any of these Licensed Professions (LP)?

Company Name

/ /

Are you a manager?

/ /

Ownership

/ /

Licensed Profession

/ /

Value

/ / / /

Corporate Business Interests:

If there is a Buy/Sell Agreement, please provide our office with a copy.

Company Name

/ /

Number of Shares

/ /

Ownership

/ /

Buy/Sell Agreement

/ /

Value

/ / / /

Sole Proprietorships:

Business Name

/ /

Description of Business

/ /

Value

/ / / /

Other Assets

Oil,and Gas and Mineral Interests:

Description, and Oil/Gas Lessee Name

/ /

Deeded Interest?

/ /

Value

/ / / /

Time Shares (Membership & Deeded):

Property Name and Address

/ /

Development Owner

/ /

Deeded Interest?

/ /

Value

/ / / / / /

Real Property Leases (exceeding one year):

Please list all real estate leases in which you are the Lessor (landlord) or Lessee (tenant).

Property Address or Description

/ /

Name of Lessee/Lessor

/ /

Annual Rents

/ / / /

Notes Receivable:

Please list all Notes Receivable (where money is owed to you), and which are not secured.

Name of Debtor(s)

/ /

Date of Note

/ /

Balance Owed

/ / / /

Mortgages and Deeds of Trust:

Please list all Mortgages and Deeds of Trust (where money is owed to you), and are secured against Real Estate

Name of Debtor(s)

/ /

Date of Note

/ /

Balance Owed

/ / / /

Intellectual Property:

Please list all registered copyright, trademark, patent and royalty interests[4].

Brief Description

/ /

Type[5]

/ /

Certificate Number[6]

/ /

Certificate Date

Pending Inheritance

Pending Inheritance:

Please indicate if you expect to acquire assets from a Pending Inheritance (from a person already deceased) or hold a power of appointment granted by someone’s trust or otherwise.

Name of Deceased Estate

/ /

Trust, Probate, Other?

/ /

Value

/ / / /

Lawsuit Judgments

Lawsuit Judgments:

Please list all judgments where you have been awarded money damages in a court proceeding.

Case Number

/ /

Court

/ /

Judgment Debtor

/ /

Judgment

/ / / / / /

Assets with Registered Title

Assets with Registered Title:

Please list all Assets with Registered Title.

Please do not list your personal automobiles, unless its value exceeds $70,000the cumulative value of all exceeds $150,000.

Description (Year, Make and Model)

/ /

Type[7]

Registration Number

Value

/ / / /

If you have any questions please call us on at (408) 356-9200.

If additional space is needed, please use an attachment.

Page 1

Trust Health Care Information

Health Care

Power of Attorney

Your Health Care Power of Attorney communicates some of your health wishes. These may include your wishes for medical treatment, end-of-life decisions, relief from pain, and organ donations.

To assist us in preparing your Health Care Power of Attorney please carefully read the following two pages, and if you wish, complete any of the sections which communicate your wishes.

Print your name:

1. WOULD YOUR HEALTHCARE POWER OF ATTORNEY’S AUTHORITY BE RESTRICTED?

My agent is authorized to make anatomical gifts, authorize an autopsy, and direct disposition of my remains, except as I state here or later in this form:

2. WHAT ARE YOUR END-OF-LIFE DECISIONS?

I direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below:

 (a) Choice Not To Prolong Life

I do not want my life to be prolonged if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits, OR

 (b) Choice To Prolong Life

I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.

3. WHAT INSTRUCTION DO YOU WANT TO MAKE REGARDING RELIEF FROM PAIN?

Except as I state in the following space, I direct that treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death:

4. ARE THERE ANY OTHER WISHES YOU WANT TO HAVE KNOWN?

(If you do not agree with any of the optional choices above and wish to write your own, or if you wish to add to the instructions you have given above, you may do so here.) I direct that:

5. WHAT ARE YOUR WISHES REGARDING DONATION OF ORGANS UPON YOUR DEATH:

Upon my death (mark applicable box):

 (a) I give any needed organs, tissues, or parts, OR

 (b) I give the following organs, tissues, or parts only.

 (c) My gift is for the following purposes (Initial any of the following that you do want):

(1) Transplant ______

(2) Therapy______

(3) Research______

(4) Education______

 (d) I do NOT want any organs, tissues or parts donated.

6. DO YOU WANT TO DESIGNATE YOUR PRIMARY PHYSICIAN (OPTIONAL)

I designate the following physician as my primary physician:

Primary Physician / Alternate Physician[8]
Physician’s Name / Physician’s Name
Physician’s Address / Physician’s Address
Physician’s Telephone / Physician’s Telephone
Primary Physician / Alternate Physician[9]
Physician’s Name / Physician’s Name
Medical Group (Example: Kaiser) / Medical Group
Physician’s Street Address / Physician’s Street Address
Physician’s City, State, Zip / Physician’s City, State, Zip
Physician’s Telephone / Physician’s Telephone

Trust Health Care Information

Health Care

Power of Attorney

Your Health Care Power of Attorney communicates some of your health wishes. These may include your wishes for medical treatment, end-of-life decisions, relief from pain, and organ donations.

To assist us in preparing your Health Care Power of Attorney please carefully read the following two pages, and if you wish, complete any of the sections which communicate your wishes.

Print your name:

1. WOULD YOUR HEALTHCARE POWER OF ATTORNEY’S AUTHORITY BE RESTRICTED?

My agent is authorized to make anatomical gifts, authorize an autopsy, and direct disposition of my remains, except as I state here or later in this form:

2. WHAT ARE YOUR END-OF-LIFE DECISIONS?

I direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below:

 (a) Choice Not To Prolong Life

 (b) Choice To Prolong Life

I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.

3. WHAT INSTRUCTION DO YOU WANT TO MAKE REGARDING RELIEF FROM PAIN?

Except as I state in the following space, I direct that treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death:

4. ARE THERE ANY OTHER WISHES YOU WANT TO HAVE KNOWN?

(If you do not agree with any of the optional choices above and wish to write your own, or if you wish to add to the instructions you have given above, you may do so here.) I direct that:

5. WHAT ARE YOUR WISHES REGARDING DONATION OF ORGANS UPON YOUR DEATH:

Upon my death (mark applicable box):

 (a) I give any needed organs, tissues, or parts, OR

 (b) I give the following organs, tissues, or parts only.

 (c) My gift is for the following purposes (Initial any of the following that you do want):

(1) Transplant ______

(2) Therapy______

(3) Research______

(4) Education______

 (d) I do NOT want any organs, tissues or parts donated.

6. DO YOU WANT TO DESIGNATE YOUR PRIMARY PHYSICIAN (OPTIONAL)

I designate the following physician as my primary physician:

Primary Physician / Alternate Physician[10]
Physician’s Name / Physician’s Name
Physician’s Address / Physician’s Address
Physician’s Telephone / Physician’s Telephone
Primary Physician / Alternate Physician[11]
Physician’s Name / Physician’s Name
Medical Group (Example: Kaiser) / Medical Group
Physician’s Street Address / Physician’s Street Address
Physician’s City, State, Zip / Physician’s City, State, Zip
Physician’s Telephone / Physician’s Telephone

HIPAA

Authorization Form

To assist us in preparing your HIPAA Authorization Form which authorizes the release of your medical information, please complete the form below.

When completing this section, please list those people whom you would want to authorize to call the hospital if anything happened to you, to find out what room you are in and how you are doing.

Please print legibly.

In the spaces provided below, please write the names of people you wish to authorize to receive your medical information. If a box is provided, please mark that box if you wish that language to appear on your HIPAPA Authorization.
Partner A: Print your name / Partner B: Print your name
□ The Trustees and Agents appointed within your estate planning documents (recommended) / □ The Trustees and Agents appointed within your estate planning documents (recommended)
□ The Law Offices of Roy W. Litherland (recommended) / □ The Law Offices of Roy W. Litherland (recommended)
□ My Spouse / □ My Spouse
□ My Children / □ My Children
List persons you want authorized below: / List persons you want authorized below:

If you have any questions please call us on at (408) 356-9200.

If additional space is needed, please use an attachment.

Page 1

Seminar Invitation Request Form

If you believe that you are better off having addressed the important issue of estate planning in your life, please help your friends find us by providing their names and addresses. Don’t worry, we will not bother them. We will simply send them a personal invitation to one of our free estate planning seminars. Or, if you have a group that would be interested in having a speaker on Estate Planning, please include the name of the group. We can include your name when sending this invitation, but if you would rather us not, please check the box to send anonymously.

 Please send anonymously

Name:
Address:
(If you don’t have it, put what you know)
Name:
Address:
(If you don’t have it, put what you know)
Name:
Address:
(If you don’t have it, put what you know)
Organization Name:
Program Coordinator Name (if known):
Program Coordinator Phone Number (if known):
Address:
(If you don’t have it all, put what you know)

We appreciate your help in growing our business and providing a service to those who are in need of help. Our mission statement is to help people to be good stewards of all that has been entrusted to them.

The Law Offices of Roy W. Litherland

3425 S. Bascom Avenue, Suite 240

Campbell, California 95008

(408) 356-9200 · (831) 476-2400

Fax: (408) 356-8901

Website:

Email:

If you have any questions please call us on at (408) 356-9200.

If additional space is needed, please use an attachment.

[1] Examples of how owned: In Trust, Jointly, Separate Property of either Spouse

[2] Please do not list accounts that you hold with children, parents, or in a business account.

[3] Is there a written appraisal of value? Yes (Y) or No (N)

[4] If you have licensed or assigned any rights to your registered intellectual properties, please inform the attorney.

[5]Registered Copyright (C), Registered Trademark (T), Registered Patent (P), or Royalty Agreement (R).

[6] No Certificate number is required for a Royalty Agreement.

[7]Vehicle (V), Pleasure Boat registered with State Department of Motor Vehicles (PB), Large Vessel registered with Coast Guard (LV), Aircraft (AC), Mobile Home registered with State Department of Motor Vehicles (MHS), or Mobile Home registered with HUD (MHH), Registered Farm Equipment/Implements (FE).

[8] If the physician I have designated above is not willing, able, or reasonably available to act as my primary physician, I designate the following alternative physician to be my primary physician.

[9] If the physician I have designated is not willing, able, or reasonably available to act as my primary physician, I designate the following alternative physician to be my primary physician.

[10] If the physician I have designated is not willing, able, or reasonably available to act as my primary physician, I designate the following alternative physician to be my primary physician.

[11] If the physician I have designated is not willing, able, or reasonably available to act as my primary physician, I designate the following alternative physician to be my primary physician.