WPC  2uB%Jo Z|xTimes New Roman (TT)Garamond (TT)C\  P6QP}Vi P1QP2?ؙphoenix#XP\  P6QXP# ESTATE PLANNING Kathy BoyteJoseph Nemelka2lJvzheading 1heading 1 ̀ Default Paragraph FoDefault Paragraph Font envelope returnenvelope return;1܄#&KVi P1Q&P##XP\  P6QXP#envelope addressenvelope address 2 |"(ll2TitleTitle  ̀ Body TextBody TextX` hp x (#` hp x (#` hp x (#X` hp x (#܁page numberpage number footerfooterX` hp x (# (# ܄#C\  P6QP##XP\  P6QXP# (# X` hp x (#ܞ2  | endnote textendnote text ;1܄#C\  P6QP##XP\  P6QXP#Body Text 2Body Text 2   ̀ 1!2x` xdd footerX` hp x (# (# page number#C\  P6QP#"page number"X` hp x (# (#  footer (# ` hp x (# X` hp x (#` hp x (#܄#` B\  P6Q` P# ESTATE    X PLANNING QUESTIONNAIRE ,  ` hp x (#` hp x (##\  P6QP# ,    ܄# k\  P6Q P#MELANIE L. GRAYSON #XP\  P6QXP#AttorneyAtLaw Grayson & Grayson Mercantile Bank Building 1 Riverfront Place, Suite 555 P.O. Box 9376 North Little Rock, AR 72119 (501) 3709192   #\  P6QP# GENERAL INFORMATION #^\  P6QP#   #y\  P6QP# YOURSELFSPOUSE #^\  P6QP# 1.Name:__________________________________________ 2.Other name or nickname known by, if any:__________________________________________ 3.Home address: __________________________________________ __________________________________________ __________________________________________  1. 1. 1. 1. 1. 1. 1. 1.Home telephone number: __________________________________________ 5.Social Security number: ____________________________________________ 6.Occupation: _____________________________________________ 7.Business address: _____________________________________________ 8.Business telephone number: ____________________________________________ #y\  P6QP# YOURSELFSPOUSE #^\  P6QP# 9.Date of birth: ____________________________________________ 10.Citizen of U.S.?  Yes No Yes No 11.Length of residence in this state: ____________________________________________ 12.Other states or countries previously resided in, and dates of residence: ____________________________________________ 13.Have you entered into any preor postnuptial agreements? (if so, attach copy):  Yes No Yes No 14.Any prior marriages (if divorced, attach copies of divorce decree and property settlement agreement; if widowed, attach copy of Form 706 (federal state tax return) for predeceased spouses estate):  FAMILY INFORMATION  #y\  P6QP# CHILDREN #^\  P6QP# NAME, CHILD 1:_______________________________ BIRTHDAY:_______________________________ SOCIAL SECURITY NO:_______________________________ ADDRESS:_______________________________ _______________________________ NAME OF SPOUSE:_______________________________ SPECIAL NEEDS:_______________________________ NAME, CHILD 2:_______________________________ BIRTHDAY:_______________________________ SOCIAL SECURITY NO:_______________________________ ADDRESS:_______________________________ _______________________________ NAME OF SPOUSE:_______________________________ SPECIAL NEEDS:_______________________________ #y\  P6QP# CHILDREN #^\  P6QP# NAME, CHILD 3:_______________________________ BIRTHDAY:_______________________________ SOCIAL SECURITY NO:_______________________________ ADDRESS:_______________________________ _______________________________ NAME OF SPOUSE:_______________________________ SPECIAL NEEDS:_______________________________ NAME, CHILD 4:_______________________________ BIRTHDAY:_______________________________ SOCIAL SECURITY NO:_______________________________ ADDRESS:_______________________________ _______________________________ NAME OF SPOUSE:_______________________________ SPECIAL NEEDS:_______________________________ #y\  P6QP# GRANDCHILDREN  #^\  P6QP# NAME:_______________________________ BIRTHDAY:_______________________________ PARENTS NAME:_______________________________ NAME:_______________________________ BIRTHDAY:_______________________________ PARENTS NAME:_______________________________ NAME:_______________________________ BIRTHDAY:_______________________________ PARENTS NAME:_______________________________ NAME:_______________________________ BIRTHDAY:_______________________________ PARENTS NAME:_______________________________ NAME:_______________________________ BIRTHDAY:_______________________________ PARENTS NAME:_______________________________ #\  P6QP# PARENTS #y\  P6QP#̀  #^\  P6QP# #y\  P6QP# YOURSELF  #^\  P6QP# FATHERS NAME:_______________________________ BIRTHDAY:_______________________________ MOTHERS NAME:_______________________________ BIRTHDAY:_______________________________ #y\  P6QP# SPOUSE #^\  P6QP# FATHERS NAME:_______________________________ BIRTHDAY:_______________________________ MOTHERS NAME:_______________________________ BIRTHDAY:_______________________________ ADVISORS: (Please list name and telephone nos.) 1.OTHER LAWYERS: _______________________________________________________ 2.ACCOUNTANT: _______________________________________________________ 3.STOCKBROKER: _______________________________________________________ 4.INVESTMENT ADVISOR: _______________________________________________________ 5.INSURANCE AGENT: _______________________________________________________ 6.OTHER (IDENTIFY): _______________________________________________________ #\  P6QP#  PERSONAL ASSETS#^\  P6QP# 1.SAVING ACCOUNTS: NAME OF INSTITUTION:______________________________ ADDRESS OF INSTITUTION:______________________________ ______________________________ FULL NAME ON ACCOUNT:______________________________ ACCOUNT NUMBER:______________________________ 2.CERTIFICATES OF DEPOSIT: NAME OF INSTITUTION:______________________________ ADDRESS OF INSTITUTION:______________________________ ______________________________ FULL NAME ON ACCOUNT:______________________________ ACCOUNT NUMBER:______________________________ 3.MONEYMARKET ACCOUNTS: NAME OF INSTITUTION:______________________________ ADDRESS OF INSTITUTION:______________________________ ______________________________ FULL NAME ON ACCOUNT:______________________________ ACCOUNT NUMBER:______________________________ 4.CHECKING ACCOUNTS: NAME OF INSTITUTION:______________________________ ADDRESS OF INSTITUTION:______________________________ ______________________________ FULL NAME ON ACCOUNT:______________________________ ACCOUNT NUMBER:______________________________ 5.STOCKS (INDICATE NAMES OF THE STOCK AND NUMBER OF SHARES): NAME OF INSTITUTION:______________________________ ADDRESS OF INSTITUTION:______________________________ ______________________________ FULL NAME ON ACCOUNT:______________________________ ACCOUNT NUMBER:______________________________ 6.BONDS (INCLUDING E, EE): NAME OF INSTITUTION:______________________________ ADDRESS OF INSTITUTION:______________________________ ______________________________ FULL NAME ON ACCOUNT:______________________________ ACCOUNT NUMBER:______________________________ 7.MUTUAL FUNDS: NAME OF INSTITUTION:______________________________ ADDRESS OF INSTITUTION:______________________________ ______________________________ FULL NAME ON ACCOUNT:______________________________ ACCOUNT NUMBER:______________________________ 8.BROKERAGE ACCOUNTS: NAME OF INSTITUTION:______________________________ ADDRESS OF INSTITUTION:______________________________ ______________________________ FULL NAME ON ACCOUNT:______________________________ ACCOUNT NUMBER:______________________________  1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1.COPYRIGHTS, PATENTS, TRADEMARKS AND OTHER INTANGIBLE RIGHTS:  MORTGAGES AND LEASES: (DESCRIBE PROPERTY AND TERMS BELOW): INTEREST IN TRUSTS AND ESTATES:  INTEREST IN LIMITED PARTNERSHIPS: (INDICATE NAME, % OF OWNERSHIP AND ORIGINAL INVESTMENT BELOW): JEWELRY AND FURS: COINS, STAMP AND OTHER COLLECTIONS: 15.ANTIQUES AND WORKS OF ART: FURNITURE AND OTHER HOUSEHOLD EFFECTS: 17.AUTOMOBILES: VEHICLE 1:_____________________________________________ VEHICLE 2:_____________________________________________ VEHICLE 3:_____________________________________________  1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1.BOATS: REAL PROPERTY (OTHER THAN RESIDENCE, PLEASE ATTACH LEGAL DESCRIPTION): 20.RESIDENCES (PLEASE ATTACH LEGAL DESCRIPTION): #\  P6QP# FAMILY BUSINESS #^\  P6QP# Name:__________________________________________________ Address:__________________________________________________ __________________________________________________ Indicate form of ownership (e.g., corporation, partnership, sole proprietorship):__________________________________________________ __________________________________________________________________ Approximate value of business:___________________________________ % of ownership: H: ____ W: ____ Children: ____ Original investment: H: ____ W: ____ Children: ____ Attach copies of buysell agreement relating to transfer of interests during lifetime or at death, employment agreements and financial statements.   #\  P6QP# LIFE INSURANCE #^\  P6QP#  1.Name of company and policy number: ______________________________________ ______________________________________ a.Type of policy (i.e., term, whole life, etc.):___________________________________ b.Insured___________________________________ c.Owner___________________________________ d.Primary beneficiary:___________________________________ e.Contingent beneficiary:___________________________________ f.Face value:___________________________________ g.Cash surrender value:___________________________________ h.Amount of outstanding  loan:___________________________________ i.Annual premium:___________________________________ 2.Name of company and policy number: ______________________________________ ______________________________________ a.Type of policy (i.e., term, whole life, etc.):___________________________________ b.Insured___________________________________ c.Owner___________________________________ d.Primary beneficiary:___________________________________ e.Contingent beneficiary:___________________________________ f.Face value:___________________________________ g.Cash surrender value:___________________________________ h.Amount of outstanding  loan:___________________________________ i.Annual premium:___________________________________ #\  P6QP#RETIREMENT PLANS #^\  P6QP# 1.Retirement Plan, YOURSELF: a.Present value:___________________________________ b.Your contribution:___________________________________ c.Vested (indicate %): ___________________________________ d.Beneficiary designation (attach copy):____________________ _______________________________________________________ 2.Retirement Plan, SPOUSE: a.Present value:___________________________________ b.Your contribution:___________________________________ c.Vested (indicate %): ___________________________________ d.Beneficiary designation (attach copy):____________________ _______________________________________________________ 3.IRA: a.Present value: ________________________________________ b.Beneficiary designation (attach copy): ____________________ _______________________________________________________ c.Where held (name and address of bank, brokerage house, or money management firm): _______________________________________________________ _______________________________________________________ _______________________________________________________ d.Type of account (custody or trust): _________________________ e.Type of investments (CD, mutual fund): ____________________ g.What is the taxable amount and the nontaxable basis? (attach a copy of Form 8606, if filed, from last years income tax return): _______________________________________________________ h.Is this IRA a conduit IRA (that could be rolled into a qualified plan)?:Yes No _________________________________ i.Is this an inherited IRA?: Yes No____________________ MISCELLANEOUS 1.Attach copies of your current wills.  1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1.Attach copies of all trust agreements in which you or a member of your family have an interest, whether as beneficiary, fiduciary, or holder of a power of appointment. 3.Attach copies of all prior federal and state gift tax returns.  1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1.Describe any inheritance you or your spouse expect to receive in the near future. 5.Have you signed a Living Will and a Health Care Proxy? Yes No If not, do you wish to do so? Yes No 6.Have you signed a durable power of attorney? Yes No If not, do you wish to do so? Yes No 7.Describe any special estate planning objectives:     ܄#XP\  P6QXP#  Body Text 2 You are now finished with the Estate planning form. To submit this form to Grayson & Grayson online, make sure you are connected to the Internet and click Submit Form. " Body Text 2" If you wish to complete this form at a later time, click Save Form. You will be prompted to save the file to your hard drive. You may resume your work by doubleclicking the downloaded file.