CONFIDENTIAL

Prepared for

Mark S. Davis, Attorney at Law

133 N 4th St, Suite 404

Lafayette, IN 47901

Phone (765) 742-7325

ESTATE PLANNING DATA

I (We) understand that this questionnaire is designed to provide Mark S. Davis, Attorney at Law with important information for estate planning purposes and that the firm's ability to advise clients with respect to lifetime and testamentary disposition of assets, with minimization of adverse tax consequences, depends on the accuracy of such information. I (We) hereby confirm that such information is substantially correct.

Dated:

INTRODUCTION

This form should be filled out as completely as possible, and forwarded to Mark S. Davis, Attorney at Law for review prior to a personal conference. Although reasonable value approximations are acceptable, it is important to be certain of the identity of assets and how they are owned. The form provides for identification of assets as owned solely by husband, solely by wife, as community property or in joint tenancy. However, please note where other conditions exist, such as tenancies in common or community property with rights of survival.

Prior to the conference, you also should consider (but need not answer on this form) the following questions, to the extent they are applicable to your situation:

1. Guardian for Minor Children. If you have children under age 18, who would you want to serve as guardian to take care of them and see to their upbringing and education in the event of your death? What about a successor guardian if the first doesn't act? Would you want the same individuals to manage their property?

2. Personal Representative/Executor. Who would you want to be the personal representative/executor of your will? This is the person or bank in charge of paying final debts and taxes and distributing your estate as directed in your will.

3. Trusts and Trustees. Trusts often are utilized for tax savings and asset management, either as part of a will, or in addition to a will. If trusts are appropriate for you (and trusts might be of long-term duration), who would you want to be the trustee (or co-trustees): A bank? An individual such as your spouse, brother or sister, child or friend? A combination of a bank and an individual? Who would be the successor trustee if the initial trustee fails or ceases to act?

4. Specific Gifts. Do you wish to provide in your estate plan for cash gifts, or gifts of other specific property, to individuals or charity? If so, you should make a list of such individuals and organizations, paying careful attention to exact given names, spellings and addresses.

5. Disaster. If all members of your immediate family are deceased, to what individuals or charities should your assets be given?

	HUSBAND	WIFE
Name
Residence Address
City, State, Zip
Citizenship*
Residence Telephone
Employer/Bus. Name
Business Address
City, State, Zip
Position
Business Telephone
Birth Date
Place of Birth
Social Security No.
Marriage Date Place
Pre-marital agreement? . If yes, please supply copy.
Husband previously married? How many times? Wife previously married? How many times?
For each prior marriage of either spouse, indicate name of prior spouse, date of marriage, date of termination, reason for termination (divorce, death) and, if divorced, whether prior spouse is living. Please supply copy of any divorce decrees.

* It is very important to plan carefully for tax or property consequences that may result from any interstate or international aspects of your estate. If you travel extensively or own residential property in more than one jurisdiction, please be prepared to discuss your views regarding what you consider to be your principal residence.

List children in order of birth, indicate if any deceased.

CHILDREN	ADDRESS	BIRTH DATE	SOCIAL SECURITY NUMBER	SPOUSE
1
2
3
4
5
6

Indicate grandchild's parent by placing the above number of such parent to the left of the grandchild's name. Indicate if any deceased.

GRANDCHILDREN

ADDRESS

BIRTH DATE

SOCIAL SECURITY NUMBER

SPOUSE

Provide information as to any adopted children or grandchildren, children of prior marriages and other relatives or friends to be considered in estate plans.

	HUSBAND	WIFE
Personal banker
Bank
Address
City, State, Zip
Accountant
Firm
Address
City, State, Zip
Stockbroker
Firm
Address
City, State, Zip
Insurance Agent
Firm
Address
City, State, Zip
Physician
Address
City, State, Zip
Safe Deposit Box:
Bank
Address
City, State, Zip
Box number(s)
Rented by (H, W, Jt.)
Other Storage:
Company
Address
City, State, Zip
Rented by (H, W, Jt.)
Please indicate whether husband and wife have current wills or trusts, including dates of execution: Husband: Location of document Wife: Location of document Please supply copies of current wills and trusts.

FINANCIAL CONDITION

It is very important to complete this page. We need to have your estimate of the approximate values of your assets, as well as the exact way they are owned (by either individual as community property or in joint tenancy). Please give careful consideration to how each asset is owned.

It is most desirable to have all of the following schedules completed, with totals carried back to this page, to assist us in considering the effects of lifetime and testamentary transfers and the tax consequences thereof. However, if you are not able to complete all of the schedules, you nevertheless should complete this page.

Provide estimated current values, in multiples of $1,000.

ASSETS	HUSBAND	JOINT TENANCY	WIFE
Cash & Notes (Sched. A)	$	$	$
Real Estate (Sched. B)
Securities (Sched. C)
Proprietorships/partnerships (Sched. D)
Life insurance (Sched. E)
Retirement assets/plans (Sched. F)
Tangible personal property (Sched. G)
Miscellaneous (Sched. H)
TOTALS	$	$	$
LIABILITIES
Mortgages (Sched. I)
Loans/notes (Sched. I)
Other liabilities (Sched. I)
TOTALS	$	$	$
NET WORTH	$	$	$

SCHEDULE A - CASH & NOTES

Provide estimated current values, in multiples of $1,000.

CASH ACCOUNTS		Type (CHKS, SAVS. C.D. MONEY MKT.)	HUSBAND	JOINT TENANCY	WIFE
Bank or Other Institution
SUBTOTAL CASH ACCOUNTS			$	$	$
LOANS OR NOTES RECEIVABLE
OBLIGOR	RATE	DATE DUE
			$	$	$
SUBTOTAL LOANS AND NOTES			$	$	$
TOTALS			$	$	$
Comments:

SCHEDULE B - REAL ESTATE

For valuation purposes, use your best estimate of current total values, without regard to any mortgages that may be outstanding. Mortgage information should be described in Schedule I. Please indicate if any property is a condominium, co-op or other restricted ownership.

Provide estimated current values, in multiples of $1,000.

ADDRESS/LOCATION		HUSBAND		JOINT TENANCY		WIFE
		COST BASIS	VALUE	COST BASIS	VALUE	COST BASIS	VALUE
1.	Residence 1	$	$	$	$	$	$
2.	Residence 2
3.
4.
5.
6.
7.
	TOTALS		$		$		$

SCHEDULE C - SECURITIES

Provide estimated current values, in multiples of $1,000.

	HUSBAND		JOINT TENANCY		WIFE
ASSET TYPE	COST BASIS	VALUE	COST BASIS	VALUE	COST BASIS	VALUE
Publicly traded stocks	$	$	$	$	$	$
S corporation stocks
Other close corporation stocks
Corporate bonds
U.S. government bonds, notes & bills
Municipal bonds
Mutual funds
Other
TOTALS		$		$		$

Please supply copies of any buy/sell agreements, related insurance arrangements, or other documents affecting any of the above securities.

Comments:

SCHEDULE D - PROPRIETORSHIPS/PARTNERSHIPS

(Including limited partnerships and tax shelters)

Provide estimated current values, in multiples of $1,000.

	HUSBAND		JOINT TENANCY		WIFE
ASSET TYPE	COST BASIS	VALUE	COST BASIS	VALUE	COST BASIS	VALUE
	$	$	$	$	$	$
TOTALS		$		$		$

Please supply copies of partnership agreements

Comments:

SCHEDULE E - LIFE INSURANCE

Provide estimated current values, in multiples of $1,000.

INSURING LIFE OF HUSBAND
COMPANY	POLICY NO.	TERM, VARIABLE LIFE, OR UNIVERSAL LIFE, OR WHOLE LIFE	FACE VALUE	CASH VALUE	LOANS	ANNUAL PREMIUM	OWNER	BENEFICIARY
			$	$	$	$
TOTAL			$

INSURING LIFE OF WIFE
COMPANY	POLICY NO.	TERM, VARIABLE LIFE, OR UNIVERSAL LIFE, OR WHOLE LIFE	FACE VALUE	CASH VALUE	LOANS	ANNUAL PREMIUM	OWNER	BENEFICIARY
			$	$	$	$
TOTAL			$

INSURING LIFE OF HUSBAND AND WIFE (SECOND-TO-DIE)
COMPANY	POLICY NO.	TERM, VARIABLE LIFE, OR UNIVERSAL LIFE, OR WHOLE LIFE	FACE VALUE	CASH VALUE	LOANS	ANNUAL PREMIUM	OWNER	BENEFICIARY
			$	$	$	$
TOTAL			$

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