Personal Information

Date

Head of Household (HOH)

Spouse

Full Legal Name (HOH)

Full Legal Name (Spouse)

Also Known As (HOH)

Also Known As (Spouse)

Date of Birth (HOH)

Date of Birth (Spouse)

U.S. Citizen? (HOH)

Yes No

U.S. Citizen? (Spouse)

Yes No

Living Parents (HOH)

Living Parents (Spouse)

Former Spouse (HOH)

Former Spouse (Spouse)

Prior Divorce Date (HOH)

Prior Divorce Date (Spouse)

Business Address (HOH)

Business Address (Spouse)

Phone (HOH)

Phone (Spouse)

Email (HOH)

Email (Spouse)

Home Address

County of Residence

Date of Marriage

2

Children

Full Name Adopted / Prior Marriage? Date of Birth Address

Do any children have a disability or handicap?

Yes No

Describe disability and any benefits received (State, Federal, or Private)

Deceased Children

Living Children of Deceased Children

HOH's Siblings

Spouse's Siblings

3

Existing Legal Documents

Last Will & Testament

Do you currently have a Last Will?

Yes No

Location of Will(s)

When drafted? Any codicils?

HOH's Personal Representative & Alternate

Spouse's Personal Representative & Alternate

HOH's Funeral Representative & Alternate

Spouse's Funeral Representative & Alternate

Medical Directives & Patient Advocacy

Do you have Medical Directives or Patient Advocacy forms?

Yes No

HOH's Patient Advocate(s) & Successors

Spouse's Patient Advocate(s) & Successors

Burial & Final Wishes

Do you have burial plots?

Yes No

Cemetery Name & Location

HOH's Funeral & Burial Wishes

Spouse's Funeral & Burial Wishes

Anatomical Gift / Body Donation Wishes

Military Burial Entitlement?

Yes No

DD-214 Location

4

Guardianship & Power of Attorney

Guardianship for Minor Children

Guardianship papers currently drafted?

Yes No No Minor Children

Proposed Guardian Name

Guardian Phone

Guardian Address

Power of Attorney

Do you currently have a Power of Attorney?

Yes (list existing agents below) No (list desired agents below)

HOH's POA Agents

Spouse's POA Agents

Agent 1 — Name

Phone

Relationship

Address

Agent 2 — Name

Phone

Relationship

Address

Agent 3 — Name

Phone

Relationship

Address

Agent 1 — Name

Phone

Relationship

Address

Agent 2 — Name

Phone

Relationship

Address

Agent 3 — Name

Phone

Relationship

Address

5

Advisors & Real Estate

Professional Advisors (held confidentially in your legal file)

Safe Deposit Box?

Yes No

Safe Deposit Location

Who Has Access

Accountant — Name & Phone

Insurance Agent — Name & Phone

Stockbroker — Name & Phone

Prior Attorney — Name & Phone

Other Professionals (Title / Name / Phone)

Real Estate

Include land contracts (mark L/C). Indicate ownership. Note any property that could be subject to Michigan tax uncapping — speak with the attorney if unsure.

Property 1 — Description & Owner

Mortgage Balance $

Market Value $

Property 2 — Description & Owner

Mortgage Balance $

Market Value $

Property 3 — Description & Owner

Mortgage Balance $

Market Value $

Has any property been inherited or been in the family for a generation or more?

Yes No

Describe inherited/family properties

6

Financial Assets & Business Interests

Cash Accounts (checking, savings, CD, money market, credit union)

Stocks & Bonds

Other Non-Business Investments or Significant Assets

Business Interests

Include corporations, LLCs, partnerships, and proprietorships. Indicate ownership: H = HOH, S = Spouse, J = Joint.

H / S / JBusiness Name / Description% InterestEst. Value

Buy-out life insurance on any business interest? (Company, policy description, amount)

Succession plan for any business interests?

Yes No

Describe desired successor and terms

7

Insurance, Retirement & Other Assets

Life Insurance

Long-Term Care Insurance

Retirement Benefits

IRA Accounts

Money Owed to You by Others

Special Household Furnishings, Autos, Collections (non-firearm)

Trust Name / Trust Assets / Current Trustee

Expected Inheritances

Gifts Over $10,000 Made by You (date and beneficiary)

Gift Tax Returns Filed?

Yes No

Years Filed

Significant Debts or Obligations (other than mortgages listed above)

8

Firearms, Criminal History & Other

Firearms

Do you or anyone in your household own firearms?

Yes No

Describe Firearms

Any family member hold a Concealed Pistol License (CPL)?

Yes No

Who holds the CPL?

Does anyone own NFA Title II weapons?

Title II includes: machine guns, short barrel rifles/shotguns, suppressors, pistols firing shotgun shells, RPGs, and other destructive devices. If unsure, describe and discuss with the attorney — this is privileged communication.

Yes No Do Not Know

Describe NFA Weapons (privileged — will not be shared)

Criminal History (privileged — will not be shared)

Have you or any family member been convicted of or pled guilty to a crime?

Yes No

Describe or discuss privately with the attorney

Medical Marijuana

Do you or any household member have a Medical Marijuana Card?

Yes No

By submitting this form, you confirm all information is accurate to the best of your knowledge. All information provided is strictly confidential and subject to attorney-client privilege. Michigan Trust | Trust & Estate Counsel

Michigan Trust

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Personal Information

Children

Existing Legal Documents

Guardianship & Power of Attorney

Advisors & Real Estate

Financial Assets & Business Interests

Insurance, Retirement & Other Assets

Firearms, Criminal History & Other

Questionnaire Submitted