ESTATE PLANNING PERSONAL INFORMATION
	
Collins & Estrem, P.A.
20 Lake Street North, Suite 202, Forest Lake, MN  55025
Appointments: 651.464.7400 x 4 / lianna@collinsestrem.com
Rob: 651.464.7400 x 1 / rob@collinsestrem.com
Julia: 651-464-7400 X 2 / julia@collinsestrem.com

Instructions:  This form is to help you gather basic information / thoughts in advance of our estate planning meeting and typically saves time at that meeting.  Not everything applies.  If you need additional space, please use the back pages of this form, or you may supplement however you’d like.  

Notes/Questions for your Attorney:  __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

Please let us know whom we may thank for referring you to Collins & Estrem, P.A. for your estate planning needs:_________________________________________________________ 

Please provide Personal Information for __________________________

Full legal name: 	_________________________________________________________
Home address: 	_________________________________________________________
City: 		___________________________	State: ____________________
County: 	___________________________	Zip: _____________________
Phone:		___________________________  	U.S. citizen?   Yes    No
Cell:	  	___________________________	Work:	___________________________
Email Address: 	_________________________________________________________
Birthdate:		_____________________	Soc. Sec. No: ______________________
Title/Occupation:	_________________________________________________________
Employer:		_________________________________________________________ 
Financial Adviser:	_________________________________________________________
Previous address: ____________________________________________________________
City: 		___________________________	State: ____________________
County: 	___________________________	Zip: _____________________
Date you moved:_____________________   Did you claim homestead? _______
Please provide Personal Information for __________________________

Full legal name: 	_________________________________________________________
Home address: 	_________________________________________________________
City: 		___________________________	State: ____________________
County: 	___________________________	Zip: _____________________
Phone:		___________________________  	U.S. citizen?   Yes    No
Cell:	  	___________________________	Work:	___________________________
Email Address: 	_________________________________________________________
Birthdate:		_____________________	Soc. Sec. No: ______________________
Title/Occupation:	_________________________________________________________
Employer:		_________________________________________________________
Financial Adviser:	_________________________________________________________
Previous address: ____________________________________________________________
City: 		___________________________	State: ____________________
County: 	___________________________	Zip: _____________________
Date you moved:_____________________   Did you claim homestead? _______

Marriage Date:	_____________________________

Please provide information concerning your Children.
Full Name:  ____________________________	Birthdate: __________________________
Child of: _______________________________ 	Number of Their Children: _____________
Address:  ______________________________ 	Phone: _____________________________
	    ______________________________	Email:  _____________________________

Full Name:  ____________________________	Birthdate: __________________________
Child of: _______________________________ 	Number of Their Children: _____________
Address:  ______________________________ 	Phone: _____________________________
	    ______________________________	Email:  _____________________________

Full Name:  ____________________________	Birthdate: __________________________
Child of: _______________________________ 	Number of Their Children: _____________
Address:  ______________________________ 	Phone: _____________________________
	    ______________________________	Email:  _____________________________

Full Name:  ____________________________	Birthdate: __________________________
Child of: _______________________________ 	Number of Their Children: _____________
Address:  ______________________________ 	Phone: _____________________________
	    ______________________________	Email:  _____________________________

Full Name:  ____________________________	Birthdate: __________________________
Child of: _______________________________ 	Number of Their Children: _____________
Address:  ______________________________ 	Phone: _____________________________
	    ______________________________	Email:  _____________________________

Full Name:  ____________________________	Birthdate: __________________________
Child of: _______________________________ 	Number of Their Children: _____________
Address:  ______________________________ 	Phone: _____________________________
	    ______________________________	Email:  _____________________________
Notes: _______________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

If either of you has had any children who are now deceased, please provide your deceased child’s name, date of birth and death, and the names of their surviving children or other descendants.   _________________________________________________________________
Please explain the special needs of any of your children due to mental or physical disabilities.     __________________________________________________________________________________________________________________________________________________________ 
Is there anything else Collins & Estrem, P.A. should be aware of relating to the children/grandchildren with respect to estate planning that you are concerned might impact their ability to receive or manage inheritance?     If so, please explain.  You are also welcome to bring this up in our meeting.  __________________________________________ __________________________________________________________________________________________________________________________________________________________
Name the persons you want to act as Guardian(s) of your minor children.
For _________________________:
Name with middle initial (in order of preference)	Address:
1.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________
2.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________ 
3.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________
For _________________________ (If same as above, please write “SAME”):
Name with middle initial (in order of preference)	Address:
1.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________
2.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________
3.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________

Name the person(s) you want as HEALTH CARE AGENT(S)
to make health care decisions for you.

For _________________________:
Name with middle initial (in order of preference)	Address:
1.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________
	Best Phone: ___________________		Email: ______________________________
2.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________
	Best Phone: ___________________		Email: ______________________________
3.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________
	Best Phone: ___________________		Email: ______________________________
Check One:	 I request /  I do not request /  I am currently undecided as to whether I desire cremation of my remains. 

For _________________________:
Name with middle initial (in order of preference)	Address:
1.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________
	Best Phone: ___________________		Email: ______________________________
2.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________
	Best Phone: ___________________		Email: ______________________________
3.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________
	Best Phone: ___________________		Email: ______________________________
Check One:	 I request /  I do not request /  I am currently undecided as to whether I desire cremation of my remains. 

Name the person(s) you want to make BUSINESS DECISIONS for you, 
while you are alive, under any Power of Attorney or Trust you might establish.
For _________________________:
Name with middle initial (in order of preference)	Address:
1.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________
2.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________ 
For _________________________ (If same as above, please write “SAME”):
Name with middle initial (in order of preference)	Address:
1.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________
2.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________
Name the persons you want to act as PERSONAL REPRESENTATIVE and/or TRUSTEE.  This is the person you want to have authority to settle and administer your Will/Trust/Estate, etc.
For _________________________:
Name with middle initial (in order of preference)	Address:
1.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________
2.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________ 
3.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________
For _________________________ (If same as above, please write “SAME”):
Name with middle initial (in order of preference)	Address:
1.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________
2.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________
3.	__________________________________	____________________________________
	Relationship to above: ______________	____________________________________

Other Questions Regarding Estate Planning.
1.	Have either of you ever given anyone over $10,000 in a year?        	Yes     	No
2.	Have either of you ever filed a federal gift tax return?		 	Yes     	No
3.	Have either of you been divorced or widowed?			        	Yes     	No
4.	Have either of you ever signed a pre-nuptial agreement?			Yes     	No
5.	Have either of you made a commitment to leave any assets 
to any person or organization?					Yes     	No
6.	Do you have a safe deposit box?						Yes     	No
7.	Have either of you made any funeral and/or burial plans?		Yes	No
8.	Do either of you have any pre-paid funeral/burial services?		Yes	No
9.	Do any of your children or others owe you money?				Yes	No
10.	Are there any children or others you want 
intentionally omitted from your estate?				Yes	No

If you answered yes to any question(s) above, please provide additional information below.  ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CHARITIES
Please list any charities that you want to make a gift to upon your death. ________________ ____________________________________________________________________________________________________________________________________________________________
ESTATE DISTRIBUTION

If you know at this time, please provide a brief overview of how you would like your estate distributed.  

Upon the first death:	____________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
Upon the second death: _________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

FINANCIAL INFORMATION 
(please add names to the columns)

Assets:			Name:  _______________ 	    Name:  _______________	           JOINT

Bank accounts 				$			$			$		
Certificates of Deposit			$			$			$		
Real estate/home			$			$			$		
Real estate/other			$			$			$		
Real estate/other			$			$			$		
Stocks/bonds/mutual funds		$			$			$		
IRAs/401Ks   				$			$			$		
Annuities 				$			$			$		
Other investment accounts		$			$			$		
Life insurance face amounts 		$			$			$		
Business interests 			$			$			$		
Personal property	    		$			$			$		
Vehicles 				$			$			$		
Anticipated inheritance			$			$			$		
Other assets: 				$			$			$		
					$			$			$		
					$			$			$		
Total Assets:			$			$			$			
Liabilities:			Name:  _______________ 	    Name:  _______________	           JOINT	

Real estate mortgages payable		$			$			$		
Loans payable				$			$			$		
Loans against life insurance		$			$			$		
Other debts:				$			$			$		
					$			$			$		
Total Liabilities:		$			$			$		

Net Amount:				$			$			$		

Please list beneficiaries and “pay-on-death” parties for bank accounts, retirement accounts, annuities, investment accounts, life insurance and similar assets on the following page.  

Please describe any business interests on the following page.

Assets of: _______________________________ with named beneficiaries, including retirement accounts, annuities, life insurance, “pay-on-death” bank accounts and “transfer-on-death” investment accounts:

							   Name of 		First 		Second
Company		  Type of Asset	     Amount	   Joint Owner 		Beneficiary      Beneficiary

____________________  ____________  $__________	 ______________    _______________			

____________________  ____________  $__________	 ______________    _______________			

____________________  ____________  $__________	 ______________    _______________ 			

____________________  ____________  $__________	 ______________    _______________			

____________________  ____________  $__________	 ______________    _______________			

____________________  ____________  $__________	 ______________    _______________			

Assets of: _______________________________ with named beneficiaries, including retirement accounts, annuities, life insurance, “pay-on-death” bank accounts and “transfer-on-death” investment accounts:

							   Name of 		First 		  Second
Company		  Type of Asset	     Amount	   Joint Owner 		Beneficiary      	  Beneficiary
  
____________________  ____________  $__________	 ______________    _______________			

____________________  ____________  $__________	 ______________    _______________			

____________________  ____________  $__________	 ______________    _______________ 			

____________________  ____________  $__________	 ______________    _______________			

____________________  ____________  $__________	 ______________    _______________			

____________________  ____________  $__________	 ______________    _______________			

Business Interests:  												

														

	
CONSENT TO
COLLINS AND ESTREM, P.A.
PRIVACY POLICY AND DUAL REPRESENTATION

We are required by the Gramm-Leach-Bliley Act to inform clients of our policies regarding privacy of client information.  We are also required by Minnesota Rules of Professional Conduct to obtain the consent of our clients when we represent more than one person in the same matter.  Please review the information below and, if you consent, sign at the bottom of the page.  

Nonpublic Personal Information We Collect.  We collect nonpublic personal information about you that is provided to us by you or obtained with your authorization.  We do not disclose nonpublic personal information about current or former clients obtained in the course of representation of those clients, except as expressly or impliedly authorized by those clients for purposes of our representation (such as discussions with your accountant, financial advisor, insurance agent or family members designated by you) or as required or permitted by law or applicable provisions of codes of professional responsibility governing our conduct as lawyers.  

Confidentiality and Security.  We retain records relating to professional services that we provide so that we are better able to assist you and, in some cases, to comply with professional guidelines or requirements of law.  In order to guard our nonpublic personal information, we maintain physical, electronic, and procedural safeguards that comply with federal regulations and our professional standards.

Destruction of Files.  We reserve the right to destroy client files seven (7) years after they are closed.

Dual Representation.  Dual representation occurs when an attorney represents two or more clients, such as a married couple, at the same time on the same matter.  Such clients may have differing interests or potential or actual conflicts of interests.  In amicable circumstances, where the clients apparently have the same objectives, using one attorney is helpful in coordinating an overall plan and in producing cost savings and other efficiencies.  If the clients do not remain amicable throughout the representation, however, the attorney will likely need to withdraw from the representation altogether.  If the attorney withdraws, clients may experience delay and additional costs in the handling of their legal matter.  With regard to client confidences in dual representation situations, the attorney cannot keep information from one or more clients.  By consenting to dual representation, the clients authorize the attorney to reveal each of their incomes, assets and liabilities, contents of documents, and other disclosures and information to all co-clients.

I have read and understand the above information, and I consent to dual representation and to the release of confidential information as outlined above. 

Dated:  ____________________									
						(Signature)

Dated:  ____________________									
						(Signature)