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CONFIDENTIAL

ESTATE PLANNING QUESTIONNAIRE

HALL GRIFFIN P.C.

9000 KEYSTONE CROSSING, SUITE 230

INDIANAPOLIS, INDIANA 46240-2148

Telephone: (317) 580-4959

Facsimile: (317) 580-4960

e-mail:

All information submitted will remain confidential. Please call us if you have any questions.

FAMILY INFORMATION

Date: ______

HUSBAND'S NAME Soc. Sec. #______

Date of Birth Are you a U.S. Citizen?______

Occupation Work Phone ( ) ______

Cellular Phone ( ) ______

WIFE'S NAME Soc. Sec. # ______

Date of Birth Are you a U.S. Citizen? ______

Occupation Work Phone ( ) ______

Cellular Phone ( ) ______

HOME ADDRESS ______

County of Residence ______

Home Phone ( )

Date of Marriage ______

CHILD #1 Name Soc. Sec. # ______

Date of Birth Telephone No. ( ) ______

Address if Different from Above ______

Is Child #1 married? Spouse's Name ______

Children of Child #1? How Many? ______

CHILD #2 Name Soc. Sec. # ______

Date of Birth Telephone No. (_____) ______

Address if Different from Above ______

Is Child #2 married? Spouse's Name ______

Children of Child #2? How Many? ______

CHILD #3 Name Soc. Sec. # ______

Date of Birth Telephone No. ( ) ______

Address if Different from Above ______

Is Child #3 married? Spouse's Name ______

Children of Child #3? How Many? ______

CHILD #4 Name Soc. Sec. # ______

Date of Birth Telephone No. (_____) ______

Address if Different from Above ______

Is Child #4 married? Spouse's Name ______

Children of Child #4? How Many? ______

If you have other children, please attach additional sheets containing the information requested above.

Any children who are now deceased? ¨Yes ¨No If so, any children of such child? ¨Yes ¨No

Have you been previously married? Husband ¨Yes ¨No

Wife ¨Yes ¨No

Are one or both of your parents living? Husband ¨Yes ¨No

Wife ¨Yes ¨No

Accountant: Name ______

Address ______

______

Work Phone ( ) ______

Financial Consultant: Name ______

Address ______

______

Work Phone ( ) ______

Life Insurance Agent: Name ______

Address ______

______

Work Phone ( ) ______

Banking Connection: Name ______

Do you or your spouse have a safety deposit box? ¨ Yes ¨ No

If so, where and in whose name? ______

Are you the owner of an interest in any business or profession? ¨ Yes ¨ No

If so, please complete the following:

Business Name ______

Business Address ______

______

Business Phone ( ) ______

Type of Business ______

______

Have either of you made gifts of any substantial amounts of property or cash or given up rights to property or cash? ¨ Yes ¨ No If so, please give details:

Have either of you ever filed a federal gift tax return (Form 709)? ¨ Yes ¨ No If so, please provide copies.

Are either of you the beneficiary of an existing trust which was established by someone else? ¨ Yes ¨ No

If so, please provide copies of trust agreements, latest asset statement and any other available information about the trust.

FINANCIAL INFORMATION

ASSETS

Please provide an estimated fair market value in all cases.

Cash / Owned by Husband / Owned by Wife / Jointly Owned
Checking
Savings
Money Market
Certificate of Deposit
Notes Receivable or Accounts Receivable
Investments / Owned by Husband / Owned by Wife / Jointly Owned
Stocks
•Est. growth rate ______%
Bonds
Mutual Funds
•Est. growth rate ______%
Annuities
Real Estate / Owned by Husband / Owned by Wife / Jointly Owned
Home
•Est. growth rate ______%
Vacation Home
What state? ______
•Est. growth rate ______%
Rental and commercial r/e
•Est. growth rate ______%
Benefits / Owned by Husband / Owned by Wife / Jointly Owned
IRA
•Est. growth rate ______%
Pension and profit sharing
•Est. growth rate ______%
401K, TIAA, CREF, etc.
•Est. growth rate ______%
Keogh
•Est. growth rate ______%
Deferred Compensation
Stock Options
Business / Owned by Husband / Owned by Wife / Jointly Owned
Value of business interest
•Est. growth rate ______%
•Is there a buy-sell agreement? ______
Personal Property / Owned by Husband / Owned by Wife / Jointly Owned
Vehicles, boats, etc.
Collectibles
Jewelry and furs
Household goods
Other Assets / Owned by Husband / Owned by Wife / Jointly Owned
(Please list)
Owned by Husband / Owned by Wife / Jointly Owned
TOTALS

LIABILITIES

Owned by Husband / Owned by Wife / Jointly Owned
Home
Vacation Home
Rental and Commercial Real Estate
Life Insurance Policy Loans
Car, Boat or Airplane
Bank Loans
Other Debt
Have you guaranteed a debt of someone else or of your business? ______If so, how much exposure? ______
TOTALS

LIFE INSURANCE

Policies on Husband
Policy 1 / Policy 2 / Policy 3
Company Name
Policy Number
Type of Policy
Face Amount
Cash Value
Cash Value Borrowed
Owner
Beneficiary
Policies on Wife
Policy 1 / Policy 2 / Policy 3
Company Name
Policy Number
Type of Policy
Face Amount
Cash Value
Cash Value Borrowed
Owner
Beneficiary
Policies on Both Lives (Last to Die)
Policy 1 / Policy 2 / Policy 3
Company Name
Policy Number
Type of Policy
Face Amount
Cash Value
Cash Value Borrowed
Owner
Beneficiary

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