Beatty & Miller, P.C. West Des Moines, Iowa

Estate Planning Questionnaire

BEATTY & MILLER, P.C.

ESTATE PLANNING QUESTIONNAIRE

Date Received ___________

IT IS EXTREMELY IMPORTANT THAT THE FAMILY DATA AND ASSETS LISTED ON THE INVENTORY CHECKLIST ARE FULLY DISCLOSED AND ACCURATE IN ORDER FOR OUR LAW FIRM TO BE INFORMED IN ORDER TO PROVIDE YOU WITH OUR PROPER ADVICE.

FAMILY DATA

1. Name: Birth Date: SSN: ________________

Occupation: _______________________ Citizenship: ______ USA ______ Other

Spouse=s Name: Birth Date: SSN: ________________

Occupation: _______________________ Citizenship: ______ USA ______ Other

2. Home Address _____________________________________ Telephone: ____________________

Street Cell:

___________________________________, _________ _________________

City State Zip

3. Business Address____________________________________ Telephone: ___________________

Street

___________________________________, _________ _________________

City State Zip

4. Spouse Business____________________________________ Telephone: ___________________

Address Street

___________________________________, _________ _________________

City State Zip

5. Email Addresses

Any other state which may be considered a domicile, such as apartment or house maintained elsewhere (including summer home) or voting address in other state? If so, please provide information:

6. Do you have:

A. A Will? Husband: Yes ( ) or No ( ) Please provide a copy.

Wife: Yes ( ) or No ( ) Please provide a copy.

B. General Financial Power of Attorney? Husband: Yes ( ) or No ( ) Please provide a copy.

Wife: Yes ( ) or No ( ) Please provide a copy.

C. Durable Power of Attorney for Health Care Decisions?

Husband: Yes ( ) or No ( ) Please provide a copy.

Wife: Yes ( ) or No ( ) Please provide a copy.

D. Declaration Concerning Life-Sustaining Procedures (a Living Will)?

Husband: Yes ( ) or No ( ) Please provide a copy.

Wife: Yes ( ) or No ( ) Please provide a copy.

7. Names and birth dates of children:

PARENTS

NAME BIRTH DATE (H, W, J)

A. __________________________ ___________ __________

B. __________________________ ___________ ___________

C. __________________________ ___________ ___________

D. __________________________ ___________ ___________

8. Advisors:

A. Attorney: _________________________ Address: _____________________________

Telephone: _______________________ _____________________________

B. Accountant: _______________________ Address: _____________________________

Telephone: ________________________ _____________________________

C. Insurance Agent: ___________________ Address: _____________________________

Telephone: ________________________ _____________________________

D. Bank: _________________________ Address: _____________________________

Telephone: _______________________ _____________________________

Safe Deposit Box: _________________

9. Special Family Information:

A. Previous marriages and commitments therefrom (attach a copy of decree and settlement papers)

_________________________________________________________________________

10. Life Insurance

A. Company name: Policy #

Owner (H or W) ____ Insured (H or W)

Death benefit $ Cash value $

Beneficiaries: 1st

2nd

B. Company name: Policy #

Owner (H or W) ____Insured (H or W)

Death benefit $ Cash value $

Beneficiaries: 1^st

2nd

C. Company name: Policy #

Owner (H or W) ____ Insured (H or W)

Death benefit $ Cash value $

Beneficiaries: 1^st

2^nd

D. Company name Policy #

Owner (H or W) ____ Insured (H or W)

Death benefit $ Cash value $_______________

Beneficiaries: 1st

2nd

INVENTORY CHECKLIST

(USE FAIR-MARKET VALUE OF ASSETS)

(Round to nearest $100.00 or $1,000.00)

HIS HER JOINT TENANTS

NAME NAME TENANTS COMMON

REAL ESTATE

A. Homestead $____________ $____________ $___________ $ ___________

B. Ag Land Acres ________

County: ____________ ____________ ____________ ___________ ___________

C. Commercial Property

Address: ______________ ____________ ____________ ___________ ___________

D. Rental Property ____________ ____________ ___________ ___________

Address: ______________

E. Vacant Lots ____________ ____________ ___________ ___________

F. Other -- out-of state ____________ ____________ ___________ ___________

Property_______________

PERSONAL PROPERTY

A. Cash $___________ $___________ $___________ $___________

B. Checking Accounts ____________ ____________ ___________ ___________

List bank name & account

numbers on back of Page 3

C. Savings Accounts ____________ ____________ ___________ ___________

List bank name & account

numbers on back of Page 3

D. Certificates of Deposit ____________ ____________ ___________ ___________

List bank name & account

numbers on back of Page 3

E. Bonds/Notes(face amount)

List Issuer & Denominations of

on back of Page 3

(1) Government ____________ ____________ ___________ ___________

(2) Municipal ____________ ____________ ___________ ___________

(3) Corporate ____________ ____________ ___________ ___________

INVENTORY CHECKLIST

HIS HER JOINT TENANTS

NAME NAME TENANTS COMMON

Stocks

(1)Held in Certificate Form

List Company & # of shrs.

on back of Page 3

____________ ____________ ___________ ___________

(2) Held in Brokerage ____________ ____________ ___________ ___________

(attach a copy of most

recent statement)

Mutual Funds ____________ ___________ ____________

(attach a copy of most

recent statement)

H. Non-Qualified Annuities

(not part of a retirement acct.) ____________ ____________

List company name, policy

number and beneficiaries on

back of Page 4

I. Retirement Funds

(1) Traditional IRA ____________ _____________

(2) Roth IRA ____________ _____________

(3) 401(K) ____________ ______________

Name of Company

(4) Pension(s) ____________ ______________

(5) Profit sharing plans ____________ _____________

(6) Qualified Annuities ____________ _____________

(7) Other Retirement

Benefits ____________ _____________

List beneficiaries of each retirement fund on back of Page 4.

J. Business Interests; LLP, LLC, Corp.,

Partnership or Sole Prop.

(1) Cash $____________ $____________ $__________ $___________

(2) Accounts Receivable ____________ ____________ ___________ ___________

(3) Inventory ____________ ____________ ___________ ___________

(4) Equipment ____________ ____________ ___________ ___________

(5) Fixtures ____________ ____________ ___________ ___________

(6) Goodwill ____________ ____________ ___________ ___________

K. Promissory Note/Contract

Receivable ____________ ____________ ___________ ___________

INVENTORY CHECKLIST

HIS HER JOINT TENANTS

NAME NAME TENANTS COMMON

L. Farm Personal Property

(1) Machinery & Equipment ____________ ____________ ___________ ___________

(2) Livestock & Poultry ____________ ____________ ___________ ___________

(3) Growing Crops ____________ ____________ ___________ __________

(4) Grain in storage ____________ ____________ ___________ ___________

M. Miscellaneous

(1) Jewelry, art objects,

collections, furs,

heirlooms, etc. ____________ ____________ ___________

(2) Cars, boats, etc. ____________ ____________ ___________

(3) Furniture & Appliances ____________ ____________ ___________

N. Anticipated Inheritance

Within One Year ____________ ____________

O. Other Assets - list:

(1) _________________ ____________ ____________ ___________ ___________

(2) _________________ ____________ ____________ ___________ ___________

P. Life Insurance

(1) Permanent ____________ ____________

(2) Term ____________ ____________

(3) Group Term ____________ ____________

LIABILITIES

A. Mortgage on home ____________ ____________ ___________ ___________

B. Mortgage on Rental or

Commercial Property ____________ ____________ ___________ ___________

C. R.E. Contract Payable ____________ ____________ ___________ ___________

D. Current Bills ____________ ____________ ___________ ___________

E. Others Debts ____________ ____________ ___________ ___________

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9/25/09