Estate Planning Information Form
The
information you provide on this form is an important beginning for us to
understand your estate planning needs.
The more completely you prepare this information prior to your
consultation, the further ahead we will be during your initial consultation. If you have a financial statement prepared by
an advisor and don’t want to fill-in everything, then please attach a copy and
spend your time completing non-financial sections.
We
appreciate you taking the time to give us this confidential information—it will
be kept in strict confidence.
Stephen
M. Waltar, PS
2025 – 112th Avenue NE, Suite 101
Near Hidden
Valley Ballparks
(See website for directions)
________________
Satellite Office (By
Appointment Only)
11 Bellwether
Way, Suite 211
[Inside Top
Mortgage Co. 360-733-9898]
Bellingham,
WA 98225
(800) 647-0626
E-Mail: Steve@Waltar.com
Website: www.waltar.com
Copyright © 2006 by
Stephen M. Waltar, PS -All Rights Reserved-
Part 1: PERSONAL
INFORMATION
Please
print very legibly! "Full name" means include full middle
name.
DATE:
____________________ Divorced Widowed Single
FULL
LEGAL NAME:
___________________________________________________________________
Name you prefer to be called by:
__________________ Birthdate:
__________________________
Social Security #:
_______________________
Occupation: ________________________________
Employer Name
___________________________________________________________________
If retired, occupation prior to
retiring: __________________________________________________
Work phone: ________________________ Citizen of what
country?: ________________________
Significant
Other (If applicable) FULL LEGAL NAME: ______________________________________
Name you prefer to be called by:
_________________ Birthdate: ___________________________
Social Security #:
_______________________
Occupation: _______________________________
Employer name:
__________________________________________________________________
If retired, occupation prior to
retiring: _________________________________________________
Work phone: ________________________ Citizen of what
country?: _______________________
RESIDENCE
ADDRESS_________________________________________________________________
City: ___________________ State: ____________ Zip: ___________ County: ______________
Mailing address (if different) or
other address: __________________________________________
City: __________________ State: ____________ Zip: ___________ County: ______________
Please
mail information to Other address: Always Seasonally: ____________________
Phone
number: _________________________ Other phone number: ______________________________
E-MAIL
ADDRESS 1: ________________________________________ home work
E-MAIL
ADDRESS 2: ________________________________________ home work
N/A Previous
marriages: Name of spouse:
___________________ Year marriage
ended: _________ Name of spouse: ___________________ Year marriage ended: _________
Part 2: FAMILY &/or BENEFICIARY
INFORMATION
Please print very legibly!
"Full name" means include full middle name.
CHILDREN
and PRIMARY BENEFICIARIES (Please write "dec"
after child's name if child is deceased)
Oldest child’s full name:
____________________________________ Nickname: _____________________
Gender: Male Female Currently a dependent? Yes No
Address
_______________________________ City ______________ State ___________ Zip
______
Birthdate:
_______________________ Social Security Number:
_____________________________
Child's
Spouse's name:
______________________________
Names of grandchildren:
______________________________________________________________
Next child’s full name:
_____________________________________ Nickname: ______________________
Gender: Male Female Currently a dependent? Yes No
Address
_______________________________ City ______________ State ___________ Zip
______
Birthdate:
_______________________ Social Security Number:
_____________________________
Child's
Spouse's name:
______________________________
Names of grandchildren:
____________________________________________________________________
Next child’s full name:
_____________________________________ Nickname: ______________________
Gender: Male Female Currently a dependent? Yes No
Address
_______________________________ City ______________ State ___________ Zip
______
Birthdate:
_______________________ Social Security Number:
_____________________________
Child's
Spouse's name:
______________________________
Names of grandchildren:
____________________________________________________________________
Next child’s full name:
_____________________________________ Nickname: ______________________
Gender: Male Female Currently a dependent? Yes No
Address
_______________________________ City ______________ State ___________ Zip
______
Birthdate:
_______________________ Social Security Number:
_____________________________
Child's
Spouse's name:
______________________________
Names of grandchildren:
____________________________________________________________________
For additional children, please copy this
form or use the back of this page
PARENTS (Please write "dec"
after parent's name if parent is deceased.
Parent's
names: Father:
_____________________________
Mother: _____________________________
Parent's
addresses N/A:
__________________________________________________________
SIBLINGS (Please write "dec"
after sibling's name if sibling is deceased.)
Siblings full names (address and phone also if
they will be agents for you):
_____________________________________________________________________________________
_____________________________________________________________________________________
Part 3:
ESTATE SUMMARY
Please either complete this or attach
a copy of your financial plan or personal financial statement
USE CURRENT FAIR MARKET VALUE FOR
EACH ASSET
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LIQUID ASSETS |
Title held solely in your
own name |
Co-owned
Assets |
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1.
Cash and Checking Accounts |
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2.
Savings Accounts |
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3.
Money-Market Funds |
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4.
Brokerage Accounts |
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5.
Stocks not in brokerage accounts |
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6.
Bonds not in brokerage accounts |
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7.
Mutual Funds |
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8.
Certificates of Deposit |
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9.
Cash/Surrender value of life insurance* |
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10.
Other _________________ |
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11. Total liquid Assets (add lines 1-10) |
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NON LIQUID ASSETS |
Title held solely in your
own name |
Co-owned
Assets |
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12.
Rental/Recreational Property (#______) |
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13.
Home(s) (#_______) |
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14.
Loans made to others |
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15.
Value of Businesses (#________) |
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16.
Death benefit of life insurance* |
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17.
Other _________________________ |
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18. Total Non-liquid Assets (Add lines 12-17) |
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RETIREMENT ASSETS |
Title held solely in your
own name |
Co-owned
Assets |
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19.
IRA’S |
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20.
Profit Sharing/pension/401(k) plans |
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21.
Other _________________________ |
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22. Total Retirement (add lines 19-21) |
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PERSONAL |
Title held solely in your
own name |
Co-owned
Assets |
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23.
Cars |
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24.
Boats/Recreational Vehicles |
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25.
Furniture |
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26.
Household goods/Misc. Personal items |
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27.
Jewelry |
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28.
Collectibles |
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29. Total personal (add lines 23-28) |
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30. TOTAL ASSETS Add lines 11, 18, 22 and 29 |
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*Follow
up Insurance Policy questions. Who is the insured?
_____________________________________ Who is the
owner? _________________ Who is/are primary
beneficiaries? ___________________________
Who
are the secondary/contingent beneficiaries?
________________________________________________
What
is the purpose of the insurance?
_________________________________________________________
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DEBTS |
Title held solely in your
own name |
Co-owned
Assets |
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31.
Credit Card Debt |
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32.
Consumer Debt |
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33.
Business Debt |
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34.
Home Mortgage* |
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35.
Rental-Property Mortgage* |
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36.
Other Debt |
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37. Total Debt (Add lines 31-36) |
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NET WORTH |
Title held solely in your
own name |
Co-owned
Assets |
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Subtract amount on line 37 from amount on line 30 |
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*Please list name and mailing address of
mortgage holder(s): ______________________
___________________________________________________________________________
INCOME
SUMMARY
Please
list All sources and amounts of monthly OR annual
income
|
INCOME SOURCES |
EMPLOYMENT $$ |
Other Sources $$ |
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1. |
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