6. Do you own any real estate or personal property located out of state?

7. If married, have you, during this marriage, lived in Arizona, California, Idaho, Louisiana, New Mexico, Nevada, Texas, Washington, or Wisconsin?

8. Do you have any trusts for yourself or other family members? Are you a party to any Buy-Sell Agreement, Stock Purchase Agreement or Partnership? If so, please bring a copy of the trust or other document to our appointment.

9. Please indicate approximate size of the estate. (NOTE: Include value of life insurance death benefits, retirement plans, investments, equity in real estate, bank accounts (even if only as a joint tenant), debts owed to you, business interests, interests in a trust where you have a right to withdraw assets for yourself or others, and all other assets):

$50,000                          $150,000                   $500,000                   More than $625,000

$1,000,000                      More than $3,000,000                   More than $5,000,000

10. Please provide a summary of your assets on the attached sheets "A" and "B". Indicate how property is owned (your name, spouse's name, or joint names), include cash value and face value of life insurance and beneficiary, and value of all assets taken into account in answering # 9 above. You may substitute a recent financial statement for sheets "A" and "B". If you have questions about any of your assets, such as the form of ownership or beneficiary designation, please bring in the relevant paperwork.

11. Do any of your beneficiaries legal minors, suffer from significant health problems, have difficulty in managing money, or are financially at risk? Who?

12. Identify persons to occupy the following positions in your estate plan:

Trustee ________________________________________________________

Alternate Trustee ________________________________________________

Executor _______________________________________________________

Alternate Executor _______________________________________________

Guardian for Minor Children ________________________________________

NOTES:

A durable power of attorney is an instrument authorizing another person(s) to act as an agent in specified matters, such as business affairs, and which becomes, or remains, effective even if the principal becomes disabled.

1. I authorize the following person (or persons) to be my agent(s) and hold the durable power of attorney:

(If two agents are named, and one dies or becomes incapacitated, the other can act, eliminating the need for successor agents.)

(A) ________________________, of ________________________, (_____)_________________.

Optional:

(B) ________________________, of ________________________, (_____)_________________.

2. Such agents may act: (Check one) A) singly__, or jointly__.
(Authorizing the agents to act singly, facilitates transactions if one is unavailable. On the other hand, requiring unanimity may operate as a safeguard against inappropriate action by a single agent.)

3. Please select on of the following:

A) _____ This power of attorney shall become effective upon my disability or incapacity. I shall be deemed disabled or incapacitated upon my agent's election to accept a physician's examination and certification that I am incapacitated mentally or physically and incapable of attending to my business affairs.

B) _____ This power of attorney shall be unconditional and effective immediately, however it shall be held in escrow by my designated representative and released only under the following circumstances:

1. To me, during my lifetime if I make a request either in writing or verbally;
   
2. To my agent, in the event he provides a written statement of my attending physician that
   I am suffering from a physical or mental disability which renders me incapable of handling my business affairs or substantially caring for myself and such condition is likely to continue for an indefinite period of time.
3. To the personal representative of my estate in the event of my death.
4. ____ In conferring power of attorney, I wish to impose a mandatory obligation to act on
   my agent. In addition, I wish to compensate my agent at the rate of ____percent of income
   (and/or ____percent of principal, or ___per hour.)

LIVING WILL

            A living will is a directive as to the withholding of life prolonging medical procedures in the event of a terminal medical condition and imminent death.

PLEASE ANSWER THE FOLLOWING QUESTIONS:

1. If my physician determines that I am in one of the following conditions for which life-prolonging procedures would serve only to artificially prolong the dying process, I direct that such procedures be withdrawn, and that I be permitted to die naturally with only medication or procedures necessary to provide comfort, care, or alleviate pain:

1. A terminal condition. [ ] Yes ; [ ] No

(A terminal condition is a condition caused by injury, disease or illness from which, to a reasonable degree of medical probability, a patient cannot recover, and either the patient's death is imminent, or the patient is in a persistent vegetative state. A persistent vegetative state is a condition caused by injury, disease or illness in which the patient has suffered a loss of consciousness with no behavioral evidence of self awareness or awareness of surroundings in a learned manner other than reflex activity of nerves and muscles for low level conditioned response, and from which to a reasonable degree of medical probability there can be no recovery.)

2. A persistent coma from which there is no reasonable possibility of recovery to a
   cognitive life. [ ] Yes ; [ ] No
   (A coma is a sleep-like unarousable condition. However, a coma may vary in duration and degree and is not necessarily a terminal condition. Accordingly, this clause may need to be qualified depending on your preferences.)
   
           (b)(1) Indicate below any qualifications regarding this condition:

2. Optional: I specifically direct that the following procedures or treatments be provided to me. (Here you may list specific life-prolonging procedures that you do not wish withdrawn, for example, nutrition and hydration by mean of nasogastric tube or tube into the stomach, intestines or veins.)

 

 

HEALTH CARE POWER OF ATTORNEY

A health care power of attorney is a designation of one or more persons to make decisions on behalf of an individual in the event the individual is incapable of doing so.

PLEASE ANSWER THE FOLLOWING QUESTION:

1. I hereby appoint ____________________, of ___________________, (____)_____________, as my agent to make health care decisions on my behalf as authorized. If ____________________ is not reasonably available or is unable or unwilling to act then I hereby appoint ___________________ of __________________, (____)______________ to serve in that capacity.