Print this form to assist in preparing and assembling necessary documents and information for an estate plan review.

A. Basic financial information.

        1. Assets (other than insurance and company/employee benefit and deferred compensation plans). To determine how assets are titled refer to brokerage account names, stock and deposit certificates, deeds, vehicle titles and bank books. A current title report for each parcel of real estate is recommended. Indicate asset values net of liens.

               Description                      Actual or Estimated Value                        How titled

                               Total assets: $______________________

           2. Liabilities:

            Description                           Balance                    Debtor                      Creditor

                    Total liabilities: $________________________

B. Insurance

The attorney will need to review your policies and beneficiary designations, including any policies with benefits arising at your death(s).

     Insurer           Type of contract              Current Value             Beneficiaries

C. List all retirement plans, deferred compensation agreements, and employee benefit plans. Your attorney will need to review written documentation for each account, including beneficiary designation forms, election forms, account agreements, and summary plan descriptions.

            Type                              Issuer or Administrator                              Current Value

D. Closely held business interests

A determination should be made of the current value of such interests. The attorney will need to review organizational and financial status documentation, including any redemption, buy-sell or other business succession agreements.

        Name of businesses        Form of Organization (Corp., LLC ,etc.)      Nature of interest

E. Personal information

On the next page list yourself first, followed by all relevant family members including grandchildren or other dependants, and any former spouse(s). The attorney will need to review your existing estate planning documents (as well as your spouse's, if available) including powers of attorney, wills, trusts and any marital property agreements.

            Name                  Relationship       Age      Occupation                Special Needs?

_________________________X_________________________________________________________

F. Trusts of which you are a beneficiary or have a power of appointment over.

If you or your spouse is a beneficiary, or has power to determine distributions or recipients, of a trust (other than your own revocable trust) identify the trusts and describe the interests or powers.

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G. Are you and your spouse U.S. citizens?________________________________

H. Total lifetime taxable gifts made by you _____________________

            by your spouse____________________

            The attorney will need to review copies of previously filed gift tax returns, if any.

I. Special concerns or objectives

Record any special concerns or objectives you wish to address with regard to your estate plan, or leave it blank and discuss it with your attorney.

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