TRUST WORKSHEET

Please complete as much as possible and we will review together during our consultation.

How were you referred to our office?

BASIC INFORMATION

Your full legal name

Other name(s) used/also known as (AKA)

Date of birth

Address

Cell Phone

Please follow this format (xxx) xxx xxxx

E-mail

Business/Employer

Occupation

US citizen?

MARITAL STATUS

2ND SPOUSE/PARTNER INFORMATION

Your full legal name

Last name, First name Middle name

Other name(s) used/also known as (AKA)

Date Of Birth

Email

Cell Phone

xxx-xxx-xxxx

Business/Employer

Occupation

Are you US Citizen?

Yes
No

Which country are you a citizen of?

CHILDREN

How many children do you have?

DISTRIBUTION OF ASSETS

Who do you want to inherit your assets and how should your assets be divided?

CONTINGENT BENEFICIARY

If in the very rare case the entire immediate family passes, who do you want to inherit your assets?

PET

Do you have pet(s)?

Yes
No

LIFE ESTATE

Is anyone else living at the house with you now besides your spouse and/or children?

Yes
No

OTHER WISHES OR CONCERNS

Do you have any other concerns?

Yes – I have a deceased child who is survived by children.
Yes – I have a disabled beneficiary who receives government assistance.
Yes – I have a beneficiary that may be involved with drug addiction, gambling or alcoholism.
Yes – I have to provide financial support for someone (aging parents, siblings, relative, etc.)
Yes – I have child(ren) from a previous relationship.
Yes – I want to disinherit somebody.
Other
No

Do you have a child who is less than 18 years old?

Yes
Not applicable

Nomination of Guardianship

List name and relationship of the person(s) other than your spouse/partner who you want to help raise your minor children

Guardian 1

Name, relationship

Guardian 2

Name, relationship

Guardian 3

Name, relationship

Trustee

List name and relationship of the person(s) other than your spouse/partner who you want to be the decision maker concerning your estate upon your death in order of priority, for example: John Smith, Husband’s brother, or Jane Doe (Wife’s mother).

Trustee 1

Name, relationship

Trustee 2

Name, relationship

Trustee 3

Name, relationship

Health Care Directive

List name and relationship of the person(s) other than your spouse/partner who you want to make health/medical decision on your behalf when you become incompetent in order of priority, for example: John Smith, Husband’s brother, or Jane Doe (Wife’s mother).

Healthcare Agent 1

Name, relationship

Healthcare Agent 2

Name, relationship

Healthcare Agent 3

Name, relationship

Power of Attorney

List name and relationship of the person(s) other than your spouse/partner who you want to make financial decision on your behalf when you become incompetent in order of priority, for example: John Smith, Husband’s brother, or Jane Doe (Wife’s mother).

POA Agent 1

Name, relationship

POA Agent 2

Name, relationship

POA Agent 3

Name, relationship

LIST OF ASSETS

Is the total value of your assets more than $5 millions?

No, less than $5M
Yes, more than $5M

Real Property

Please list the addresses of all real property that you have your name on, including vacant land.

Other assets

Please list your bank account, safety box, retirement, life insurance, investment…

END-OF-LIFE DECISIONS

Select the statement which best states your desires:

Pull the plug or not?

Yes – 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
No – Choice to Prolong Life: I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.
Undecided

Organ Donation

Would you like to donate your organs or part of your body? (Check all that apply)

BURIAL WISHES

SPOUSE'S HEALTHCARE DIRECTIVE

List name and relationship of the person(s) other than your spouse/partner who you want to make health/medical decision on your behalf when you become incompetent in order of priority.

Same choices as my spouse's

Yes
No, I want different individuals

SPOUSE'S HEALTHCARE AGENTS

Spouse's Healthcare Agent 1

Name, relationship

Spouse's Healthcare Agent 2

Name, relationship

Spouse's Healthcare Agent 3

Name, relationship

Spouse's Healthcare Agent 4

Name, relationship

SPOUSE'S POWER OF ATTORNEY

List name and relationship of the person(s) other than your spouse/partner who you want to make financial decision on your behalf when you become incompetent in order of priority

Same choices as my spouse's

Yes
No, I want different individuals

SPOUSE'S POWER OF ATTORNEY AGENTS

Spouse's POA Agent 1

Name, relationship

Spouse's POA Agent 2

Name, relationship

Spouse's POA Agent 3

Name, relationship

Spouse's POA Agent 4

Name, relationship

1 be: at:

SPOUSE'S END-OF-LIFE DECISIONS

Select the statement which best states your desires:

Spouse – Pull the plug or not?

Yes – 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
No – Choice to Prolong Life: I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.
Undecided

Spouse – Organ Donation Would you like to donate your organs or part of your body? (Check all that apply)

SPOUSE – BURIAL WISHES

Spouse – At my death, I wish to be:

cremated
buried
other
green/natural burial

Spouse – I would like to be buried at:

I have already made pre-arrangements at:

TRUST WORKSHEET

BASIC INFORMATION

2ND SPOUSE/PARTNER INFORMATION

CHILDREN

DISTRIBUTION OF ASSETS

CONTINGENT BENEFICIARY

PET

LIFE ESTATE

OTHER WISHES OR CONCERNS

Nomination of Guardianship

Trustee

Health Care Directive

Power of Attorney

LIST OF ASSETS

END-OF-LIFE DECISIONS

Organ Donation

BURIAL WISHES

Pre-arrangements

SPOUSE'S HEALTHCARE DIRECTIVE

SPOUSE'S HEALTHCARE AGENTS

SPOUSE'S POWER OF ATTORNEY

SPOUSE'S POWER OF ATTORNEY AGENTS

SPOUSE'S END-OF-LIFE DECISIONS

SPOUSE – BURIAL WISHES