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TRUST WORKSHEET

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

How were you referred to our office?

Metlife Eligibility ID #

ARAG Member ID #

Case Assist #

Please let us know who referred you to us (friend, family, co-worker, etc.)

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?

Which country are you a citizen of?

CHILDREN

How many children do you have?

Child 1

Please enter your child’s name.

Date Of Birth

Child 2

Please enter your child’s name.

Date Of Birth

Child 3

Please enter your child’s name.

Date Of Birth

Child 4

Please enter your child’s name.

Date Of Birth

Child 5

Please enter your child’s name.

Date Of Birth

Child 6

Please enter your child’s name.

Date Of Birth

DISTRIBUTION OF ASSETS

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

I would like to divide my assets as follows:

CONTINGENT BENEFICIARY

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

Please explain

PET

Do you have pet(s)?

Yes
No

PET TRUST

Dog
Cat

LIFE ESTATE

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

Yes
No

Please list name and relationship

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

Guardian 4

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

Trustee 4

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

Healthcare Agent 4

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

POA Agent 4

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)

Yes - for transplant
Yes - for therapy
Yes - for research
Yes - for education
No, I do not wish to donate.

BURIAL WISHES

At my death, I wish to be:

cremated
buried
other
green/natural burial

I would like my ashes to be

scattered at sea
kept at home
stored at my place of worship
disposed at the discretion of my family
other
undecided

I would like to be buried at:

Pre-arrangements

I have already made pre-arrangements at:

MARITAL STATUS

Never Married
Divorced
Widowed
Currently Married
Registered Domestic Partner

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?

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

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)

Yes - for transplant
Yes - for therapy
Yes - for research
Yes - for education
No, I do not wish to donate.

SPOUSE - BURIAL WISHES

Spouse - At my death, I wish to be:

cremated
buried
other
green/natural burial

Spouse - I would like my ashes to be:

scattered at sea
kept at home
stored at my place of worship
disposed at the discretion of my family
other
undecided

Spouse - I would like to be buried at:

I POA have

I have already made pre-arrangements at:

Law Offices of Katie Le

10971 Garden Grove Blvd, Suite G,

Garden Grove, CA 92843

2445 McCabe Way, 2nd Floor,

Irvine, CA 92617

13700 Veterans Memorial Dr, Suite 103,

Houston, TX 77014

Contact

(855) 535-2843 (855 LE KATIE)

info@katiele.com

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