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

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 moved: ___________________  Did you claim homestead ______________

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

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

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

If you have 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.
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.
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.
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 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.
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 you ever given anyone over $10,000 in a year?        	Yes     	No
2.	Have you ever filed a federal gift tax return?		 	Yes     	No
3.	Have you been divorced or widowed?			        	Yes     	No
4.	Have you ever signed a pre-nuptial agreement?			Yes     	No
5.	Have 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 you made any funeral and/or burial plans?			Yes	No
8.	Do 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. ___________________________________________________________________  
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

FINANCIAL INFORMATION 

Assets:			

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:				

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 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 & ESTREM, P.A.
PRIVACY POLICY 

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.

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)