CONFIDENTIAL ESTATE PLANNING QUESTIONNAIRE FOR …...assets in your name which are subject to probate at your death, paying all your debts, expenses, and taxes, filing all required

Client Names:

Date Completed:

This questionnaire will assist your von Briesen & Roper, s.c. attorney in identifying the tax and non-tax issues

relevant to your estate plan. Estimates rather than exact figures should suffice for the financial information. If you

prefer, you may attach a recent financial statement which includes information requested in the personal financial

statement section and fill in the remaining items as appropriate.

Toll Free Number for all Locations: 800.622.0607

Milwaukee Office:

411 East Wisconsin Avenue, Suite 1000

Milwaukee, WI 53202

414.276.1122

Waukesha Office:

20975 Swenson Drive, Suite 400

Waukesha, WI 53186

262.241.5600

Neenah Office:

55 Jewelers Park Drive, Suite 400

Neenah, WI 54956

920.702.5300

Madison Office:

10 East Doty Street, Suite 900

Madison, WI 53703

608.441.0300

Green Bay Office:

300 North Broadway, Suite 2B

Green Bay, WI 54303

920.713.7800

CONFIDENTIAL ESTATE PLANNING QUESTIONNAIRE FOR MARRIED PERSONS

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GENERAL DATA Personal Information Spouse #1 Spouse #2

Name: Name:

Social Security Number: Social Security Number:

Date of Birth: Date of Birth:

Occupation: Occupation:

Employer: Employer:

Home Address:

Home Phone: Spouse #1’s Alt. Phone: Spouse #2’s Alt. Phone:

Spouse #1’s Email Address: Spouse #2’s Email Address:

County of Residence: Year Married: State Married: Children Attach additional sheets if needed. Indicate if deceased. Name (first, last) M / F

Date of Birth Address Spouse Name Child’s Children Names/DOB (grandchildren) Name (first, last) M / F

Date of Birth Address Spouse Name Child’s Children Names/DOB (grandchildren)

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Name (first, last) M / F

Date of Birth Address Spouse Name Child’s Children Names/DOB (grandchildren) Name (first, last) M / F

Date of Birth Address Spouse Name Child’s Children Names/DOB (grandchildren) Prior Marriages Spouse #1 _______ Yes _______ No If yes, to whom: How and when marriage ended: Were there children from this marriage: If so, list names and DOB:

Spouse #2 _______ Yes _______ No If yes, to whom: How and when marriage ended: Were there children from this marriage: If so, list names and DOB:

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ESTATE PLANNING DOCUMENTS

Indicate if you currently have in effect any of the following estate planning documents: Yes No

Will

Revocable Trust

Durable Power of Attorney for Financial Matters

Health Care Power of Attorney

Declaration to Physicians (Living Will)

Marital Property Agreement

Prenuptial Agreement

Irrevocable Life Insurance Trust

Funeral Forms

Other: Who drafted these documents: Please provide us with copies of current documents.

Do you have beneficiary designations on file for insurance policies or retirement plan benefits? Do you have a TOD (transfer on death) on any account naming a beneficiary other than each other? Do you have any accounts held jointly

with anyone other than each other? If yes, to any of the above, please provide details.

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PROFESSIONAL ADVISORS

Banking Advisor

Advisor Name Bank

Address City State ZIP

Phone Email

Accountant

Advisor Name Bank


Phone Email

Investment Manager

Advisor Name Bank


Phone Email

Investment Manager

Advisor Name Bank


Phone Email

Stockbroker

Advisor Name Bank


Phone Email

Insurance Agent

Advisor Name Bank


Phone Email

Spouse’s Physician

Advisor Name Bank


Phone Email

Spouse’s Physician

Advisor Name Bank


Phone Email

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BACKGROUND INFORMATION Yes No 1. Has either of you received a substantial amount of property from an inheritance,

a gift, or as a beneficiary of a trust? If so, please describe. 2. Do you anticipate any sizeable inheritance? If so, please describe. 3. Are you or any or your children the beneficiary or trustee of a trust created under

a Will or a written trust agreement? If so, please describe. 4. Does a third party (individual or corporation) own life insurance on the life of

either of you or do you own life insurance on the life of someone else? If so, please indicate the name of the owner, the cash value, and the face amount of the policy(ies) on the financial statement at the end of this worksheet.

5. Do you have a safe deposit box? If so, please indicate in whose name(s) it is

rented and its location: 6. Is either spouse not a United States citizen? 7. Has either spouse made any taxable gifts or filed a gift tax return? 8. Are any of your children or grandchildren currently receiving any governmental

or state benefits due to a disability or medical need, i.e., SSI benefits?

9. Do any of your children or grandchildren have special needs that should be

considered in your estate planning documents? If so, please explain: _________________________________________________________________ 10. Are any of your children not also children of your current spouse? If so, please

explain: __________________________________________________________ 11. Are any of your children adopted? If so, list who and the adoption date: 12. Are there any children who are living as family members but who have not been

adopted? If so, please explain: 13. Are you the owner of any Edvest Accounts and if so, have you appointed

successor owners? Please describe:

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PERSONAL REPRESENTATIVES, TRUSTEES, ATTORNEYS-IN-FACT, GUARDIANS The following is a brief description of the positions that need to be addressed in estate planning documents. Please consider who you may want to name and provide addresses and phone numbers for those whom you expect to include. We will discuss this more fully during our meeting before any final decisions are made. Personal Representatives The Personal Representative is responsible for filing your Will with the Probate Court after your death, collecting all of the assets in your name which are subject to probate at your death, paying all your debts, expenses, and taxes, filing all required tax returns, and ultimately distributing your assets to your named beneficiaries pursuant to your Will. If you decide to use a Revocable Living Trust as the primary instrument in your estate plan, then there may be no probate estate in which case most of the duties traditionally performed by the Personal Representative would be performed by the Trustee(s). For this and other reasons, many people name the same person or persons, or trust company, as Personal Representatives and Trustees. You can name Co-Personal Representatives. Trustees Your Will may provide for the creation of one or more Trusts upon your death. In addition, you may decide to employ a Revocable Living Trust as the primary instrument in your estate plan, in lieu of having a Will serve as the primary instrument. In either case, it will be necessary to designate a Trustee to serve after either of you dies or becomes disabled, and also successor Trustees after the death of the survivor of you. There is no requirement that the Trustee be a Wisconsin resident. The Trustee may be any individual over 18 years of age or a Trust Company. Initially, both of you can serve as Trustee of your Revocable Trust, and, following the first death, the surviving spouse can continue to serve as Trustee. Please keep in mind that the Trustee’s primary function is to manage and invest funds and to distribute the Trust principal and income in accordance with the Trust’s provisions. You can name Co-Trustees. Agent for Health Care Power of Attorney Your estate planning documents will include a durable power of attorney for health care. In this document you appoint the person or persons you wish to grant authority to make health care decisions on your behalf in the event you become incapacitated. It is common for one spouse to serve as agent for the other. You may, but are not required to, name a successor to serve if your first agent is unable to serve. Attorneys in Fact for Durable Power of Attorney for Financial Matters Your estate planning documents will also include a durable power of attorney granting broad powers to manage your personal matters and financial matters such as signing checks on your behalf, buying and selling property on your behalf, accessing your safe deposit box, filing tax returns for you, and so forth. It is common for spouses to designate each other as their primary attorney-in-fact. You can name more than one person to serve as co-agents. Guardians Disregard this section if there are no minor children. If any of your children are under the age of 18 at the death of the survivor of you, a guardianship will be necessary for each of your minor children. The Guardian(s) is (are) the person(s) with whom your minor child(ren) will live and who will be responsible for the care of the child(ren) on a day-to-day basis. The Guardian does not need to be a Wisconsin resident. If you have certain people in mind to fill these roles, please include their names, addresses and phone numbers.

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Name: Address: Phone: Name: Address: Phone: Name: Address: Phone: Name: Address: Phone: Name: Address: Phone: Name: Address: Phone: Name: Address: Phone: Name: Address: Phone:

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CLOSELY HELD BUSINESS INFORMATION Name of Company: Type of Entity: Corporation General Partnership Sole Proprietorship

C Corporation Limited Partnership Limited Liability Partnership (LLP) S Corporation Limited Liability Company (LLC) Year Business Formed or Purchased: Type of Business Conducted: Names of Owners and Percentage Owned: ( ) ( ) ( ) Gross Annual Revenue: Number of Employees: Book Value (assets less liabilities) Estimated Value of Business: Business Valuation Method: Appraisal Client Estimate CPA Buy/Sell Agreement

Estimated Growth Potential in Value of Business:

Buy-Sell Agreement: Yes No Date Prepared: Buy-Sell Fully Funded by Insurance? Estimated Annual Salary and Bonuses Paid to Owners: Type of Qualified Retirement Plan: Qualified Plan Investment Trustee: Names and Relationships of Other Family Members Involved in Business: Key Man Insurance? Disability Program? Please provide copies of the following: most recent annual minutes of directors and shareholders meetings; Buy-Sell Agreement and any amendments; most recent federal income tax return for the business; most recent balance sheet and annual income statement for business.

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Completing this summary with the approximate value of your assets and liabilities will assist us in developing your overall estate plan, assessing your needs for tax planning, and anticipating situations that might arise upon your death. Although detailed information regarding each and every asset is not required at this stage, providing more detailed information requested in the enclosed schedules will be extremely helpful. If you have a recent financial statement, however, you may attach it instead.

ASSETS SPOUSE #1 SPOUSE #2 JOINT

Tangible Personal Property (Schedule A) $ $ $

Cash & Notes Receivable (Schedule B)

Real Estate (Schedule C)

Securities (Schedule D)

Proprietorships/Partnerships (Schedule E)

Closely-Held Businesses (Schedule F)

Life Insurance Death Benefit (Schedule G)

Retirement Assets/Plans (Schedule H)

Stock Options (Schedule I)

Miscellaneous (Schedule J)

TOTALS: $ $ $

LIABILITIES

Mortgages (Schedule K) $ $ $

Loans/Notes Payable (Schedule K)

Other Liabilities (Schedule K)

TOTALS: $ $ $

ESTATE NET WORTH (Assets-Liabilities)

$ $ $

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PERSONAL FINANCIAL STATEMENT

Spouse #1’s Name: Spouse #2’s Name: Date:

NOTE: It is very important to obtain accurate information regarding how assets are presently titled. The values of assets should be placed in the appropriate column. If you have a current financial statement prepared by your financial advisor, accountant, or other agent, you may attach that hereto rather than filling out the following tables.

SCHEDULE A – TANGIBLE PERSONAL PROPERTY

SPOUSE #1 SPOUSE #2 JOINT/COMMUNITY

Furniture and Furnishings $ $ $

Automobiles

Works of Art or Art Collections

Other Collections

Jewelry and Furs

Other

Other

Other

Other

Other

Other

Other

TOTALS: $ $ $

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SCHEDULE B – CASH EQUIVALENTS & NOTES RECEIVABLE

CASH ACCOUNTS

Bank or Other Institution

TYPE OF ACCOUNT

(Checking, Savings, CDs, Money Market)

CURRENT BALANCE

SPOUSE #1 SPOUSE #2 JOINT

$ $ $

NOTES RECEIVABLE

PAYABLE TO

DEBTOR REMAINING TERM SPOUSE #1 SPOUSE #2 JOINT

TOTAL CASH & NOTES RECEIVABLE: $ $ $

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SCHEDULE C – REAL ESTATE

Indicate estimated value without regard to mortgages (which should be described in Schedule K). Indicate if property is a condominium, cooperative or other restricted ownership.

REAL PROPERTY

Use, Address & Location

APPROXIMATE COST BASIS

CURRENT MARKET VALUE:


1. Residence $ $ $ $

2.

3.

4.

5.

TOTALS: $

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SCHEDULE D – SECURITIES

TYPE OF SECURITY OR INVESTMENT




Brokerage Accounts: $ $ $ $

Publicly Traded Stocks: (held directly with company)

Mutual Funds

Corporate Bonds

U.S. Government Bonds/Notes/Bills

Municipal Bonds

Other (Specify)

TOTALS: $ $ $ $

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SCHEDULE E –PARTNERSHIPS AND TAX SHELTERS

Please supply copies of partnership agreements.

DESCRIPTION OF PARTNERSHIP (Name, asset, etc.)




$ $ $ $

TOTALS: $ $ $ $

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SCHEDULE F – CLOSELY-HELD BUSINESS INTEREST

Please include any agreements that restrict purchase or sale.

NAME AND TYPE OF BUSINESS (C or S corporation, LLC, etc.)




$ $

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

$

Percentage held:

TOTALS: $

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SCHEDULE G – LIFE INSURANCE

(1) POLICIES INSURING THE LIFE OF SPOUSE #1

1. Company: Policy Number: Annual Premium $

Death Benefit $ Type of Policy: Term Whole Life Variable Life Universal Life

Cash Value (if any) $ Loans (if any) $

Current Owner: Current Beneficiary:









TOTALS:

(2) POLICIES INSURING THE LIFE OF SPOUSE #2













TOTALS:

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SCHEDULE G – LIFE INSURANCE (continued)

(3) POLICIES INSURING SPOUSE #1 & SPOUSE #2 (SECOND-TO-DIE)













TOTALS:

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SCHEDULE H – IRAs, 401(k)s, AND OTHER RETIREMENT ASSETS/PLANS

Retirement Assets of Spouse #1

1. Type of Plan: Traditional IRA Roth IRA 401(k) Roth 401(k) 403(b) Other

Custodian for Employer: Current Value $ Vested Percentage %

Annual Contribution $: Current Beneficiary:







TOTALS:

Retirement Assets of Spouse #2










TOTALS:

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SCHEDULE I – EMPLOYER GRANTED STOCK OPTIONS AND RESTRICTED STOCK

Please provide a copy of each plan document and a printout of your current options/ shares with strike prices, expiration dates and other similar information.

Spouse #1

EMPLOYER OR COMPANY NAME

TYPE OF PLAN

CURRENT VALUE

VESTED PORTION

EXPECTED FUTURE GRANTS

CURRENT BENEFICIARY

(if any)

TOTALS:

Spouse #2

EMPLOYER OR COMPANY NAME

TYPE OF PLAN

CURRENT VALUE

VESTED PORTION

EXPECTED FUTURE GRANTS

CURRENT BENEFICIARY

(if any)

TOTALS:

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SCHEDULE J – MISCELLANEOUS

List estates and trusts where an outright inheritance is expected, and provide estimated value thereof. Also list values where you have powers to control the dispositions of the assets. Please supply copies of relevant wills and trusts.

SPOUSE #1 SPOUSE #2

Interests in pending probate estates: $ $

Interests in existing trusts:

Expected interests in future estates or trusts:

TOTALS:

Do you currently hold any fiduciary positions (executor, trustee, guardian, custodian?) If yes, please explain:

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SCHEDULE K – LIABILITIES

List here only significant liabilities, such as mortgages on real estate, notes or loans due to others.

MORTGAGES (Identify property by using numbers listed in Schedule B)


1. Residence

2.

3.

4.

5.

TOTALS:

LOANS & NOTES PAYABLES (Identify Creditor)


1.

2.

3.

4.

5.

TOTALS:

OTHER LIABILITIES (Include charitable pledges)


1.

2.

3.

4.

5.

TOTALS:

33256464_2.DOC

Documents

CONFIDENTIAL ESTATE PLANNING QUESTIONNAIRE FOR …...assets in your name which are subject to probate at your death, paying all your debts, expenses, and taxes, filing all required