Chair of the Federal & State Credit Union Department & Coordinator of legal consultations under the Family Legal Care Plans offered to credit union members.

CREDIT UNION: ______________________________________                                                 DATE:__________________

ATTORNEY: ________________________   ____________________________________  ____________________________________                       INTERVIEW                                 DRAFT                                                                 LOCATION OF INTERVIEW

WILL APPLICATION  FORM  - PLEASE  PRINT

(Fill out and bring to appointment, i.e.: print out, e-mail or call in for one)

NAME:                                                                                                                               

  SS#:   ___________________________________

DATE OF BIRTH: ________________________  

ADDRESS __________________________________________________________________   RELIGIOUS  PREFERENCE__________________________

         ________________________________________________________ 

         (Please include Street, P.O. Box, City or Town, State & Zip)

Own Home Yes ___ No___   Approx. market value $_____________  Mortgage Balance $______  Rent _________    

Do own other real estate: Yes _____ No _____

Property Address: ___________________________________________________________________________________________

                                            (Use additional sheet if needed)

  TELEPHONE NUMBERS:  work_______________ home_____________

 MARITAL STATUS:    SINGLE ___________ MARRIED ________   DIVORCED __________

                    WIDOW ___________ WIDOWER __________ SEPARATED ________

SPOUSE’S NAME:____________________________        SPOUSE’S  SS#:                                                  

DATE OF BIRTH____________________________

SPOUSE’S WORK TELEPHONE NUMBER: ______________________________        HOME: _____________________________(IF NOT SAME)

RELIGIOUS PREFERENCE_________________________________________            

NUMBER OF CHILDREN, NAMES AND AGES                                SPOUSE’S NAME                                  AGES OF GRANDCHILDREN                                        

A.______________________                   A.___________                    A.___________________

B.______________________                B.___________                B.___________________

C.______________________               C.____________               C.___________________

D.______________________                   D.____________                   D.___________________

                                             ( use additional sheet if needed)

GUARDIAN TO RAISE MINOR CHILDREN                1^ST CHOICE _________________   

                                                                     2^ND CHOICE__________________

GUARDIAN OF MINOR CHILDREN’S ESTATE           1^ST CHOICE__________________            

                                                                     2^ND CHOICE__________________

                                                                (USE ADDITIONAL SHEET FOR ADDRESSES, TELEPHONE NUMBERS, ETC)  

OTHER FAMILY (PARENTS, SIBLINGS, AUNTS, UNCLES):

Name :____________________________         Name :____________________________ 

Address :__________________________         Address :__________________________ 

                 __________________________                          __________________________

Phone:____________________________         Phone:____________________________

Relationship:_______________________        Relationship:_______________________ 

Name :____________________________        Name :____________________________     

Address :__________________________        Address :__________________________              

                __________________________                        ___________________________ 

Phone:____________________________        Phone:____________________________ 

Relationship:________________________       Relationship:_______________________      

 GENERAL ASSET INFORMATION

Primary financial Institution: ____________, ____________, ____________, ____________                                              Name                          Address                       City                             State  

           Checking ___________     Savings __________  IRAs ___________

Secondary financial institution: ____________, ____________, ____________, ____________                                                Name                           Address                       City                             State  

           Checking ___________     Savings __________  IRAs ___________

EMPLOYER  401K__________________  PENSION ______________________    OTHER _____________________________

ESTIMATED VALUE OF ENTIRE ESTATE (of both spouses if married) INCLUDING INSURANCE, HOME, ALL SAVINGS, 401Ks, IRA’s, 

STOCKS AND  BONDS, ETC:

$_____________

Estimate :  in excess of $675,000.00 for the years  2000 & 2001?   YES  ___ NO___

All assets of the estate are to be given to the following person(s):

a.     Spouse Yes _____No____     b.  Then,  children , equally ? Yes ___ No____   

                    c.  Others _____________________

                                     (use additional sheet if necessary )

        EXCEPTIONS: _________________________________________________________ ( use additional sheet if necessary )

  b.    Grandchildren to receive share a deceased child would have received 

       if child predeceases me? __yes ___no  

       if I predecease child?     ___yes ___no

EXECUTOR:    a.   Spouse  Yes ___No____   b.  Name if other than spouse______________________  

 Address :____________________________                                Relationship:_______________

            ____________________________

               ____________________________                                 Telephone:________________

Alternate Executor if first can not serve:    Name____________________________

Address:_____________________________                        Relationship:_______________

            _____________________________

                    telephone:________________

POWER OF ATTORNEY:  Individually, you, the PRINCIPAL, appoint as your AGENT under this Power of Attorney.

 a.  Spouse ________ Other if not spouse:             Telephone:________________ Name:___________________________                                                                                                  Address:_________________________________________________________________ 

b. Alternate:   Name ___________________________________________

                  Address ___________________________________________       

                   Telephone No. ____________________

LIVING WILL AND HEALTHCARE POWER OF ATTORNEY

First choice of person to represent you :    a.  Spouse _______b. Name if not spouse_________________________________

                                                                                                        Address:______________________________          Telephone: ____________________   

            ______________________________   

Second Choice (usually a blood relative and often different from the one spouse chooses for healthcare/living will decisions) 

Name: ______________________  Relationship____________ Address_______________________________________

Telephone no._____________________                          

SECTION TO BE FILLED OUT AT APPOINTMENT WITH ATTORNEY 

I/we agree to have the following estate planning documents prepared for the total fee of $_________

Simple Will____; 

Complex Will____; 

Junior Estate Plan (JEP) which includes a Will, living will, Powers of Appointment for property, for health care.____

Senior Estate Plan (SEP) which includes items in a JEP plus tax shelter trusts. _____

______________________________________         ________________________________________

signature                                        signature

FEE PAID $__________                               FEE DUE $__________________

Comments: ___________________________________________________________________________________

          ___________________________________________________________________________________

          ___________________________________________________________________________________

          ___________________________________________________________________________________

          ___________________________________________________________________________________