DATE _____________________ REFERRED BY _________________________

NAME ____________________________________ BIRTHDATE _____________

SPOUSE __________________________________ BIRTHDATE _____________

HOME ADDRESS ____________________________________________________

CITY ___________________________ STATE ___________ ZIP __________

HOME TELEPHONE ( )

WORK PLACE-HIS __________________________________________________

ADDRESS__________________________________________________________

WORK TELEPHONE ( )

WORK PLACE-HER __________________________________________________

ADDRESS__________________________________________________________

WORK TELEPHONE ( )

SOCIAL SECURITY #: YOU __________________ SPOUSE ________________

MARITAL STATUS: [] MARRIED [] SINGLE [] WIDOW(ER) [] DIVORCED

[] LEGALLY SEPARATED

UNITED STATES CITIZEN: YOU: [] YES [] NO; SPOUSE [] YES [] NO

CLIENT(S) ______________________________ FILE # _________________

PLEASE BRING TO THE FIRST CONFERENCE AS MANY OF THE FOLLOWING DOCUMENTS AS ARE APPLICABLE TO YOU (check those which apply):

[] Existing Wills or Trust Agreements;

[] Life Insurance Policies;

[] Divorce Decrees and Property Settlement Agreements;

[] Deeds and Lease Agreements for Real Estate;

[] Employee Benefit and Retirement Plans;

[] Corporation Documents and Shareholder Agreements;

[] Partnership Agreements;

[] Deeds of Trust and Notes for Money Owed to You;

[] Last Year's Income Tax Returns;

[] Gift Tax Returns;

[] Any Other Information That Might Be Important.

I. CHILDREN: (indicate if adopted)

1. NAME ________________________________ BIRTHDATE ________________

CHILD'S SPOUSE _________________________ MINOR CHILDREN? []YES []NO

CITY AND STATE _________________________

2. NAME ________________________________ BIRTHDATE ________________

CHILD'S SPOUSE _________________________ MINOR CHILDREN? []YES []NO

CITY AND STATE _________________________

3. NAME ________________________________ BIRTHDATE ________________

CHILD'S SPOUSE _________________________ MINOR CHILDREN? []YES []NO

CITY AND STATE _________________________

4. NAME ________________________________ BIRTHDATE ________________

CHILD'S SPOUSE _________________________ MINOR CHILDREN? []YES []NO

CITY AND STATE _________________________

5. OTHER (use separate sheet)

H. DEBTS, MORTGAGES AND LIENS Current Value

Debts Owed _____________

Mortgages on Property _____________

Bank Loans _____________

Insurance Policy Loans _____________

Installment Contracts _____________

Contingent Liabilities (guaranty, indemnity _____________

agreements)

I. APPROXIMATE ANNUAL INCOME Amount

Salary _____________

Fees _____________

Commissions _____________

Interests _____________

Dividends _____________

Pensions _____________

Annuities _____________

Royalties _____________

Trust Income _____________

Payments receivable on mortgages, _____________

installment sales, etc.

TOTAL _____________

J. FUTURE INHERITANCES

Do you, your spouse or your children expect to inherit property? From whom? Estimated amount?

ASSETS CURRENT VALUE

1. Real Estate _____________

2. Closely-held corp. stock _____________

3. Listed securities _____________

4. Cash _____________

5. Mortgages and promissory notes _____________

6. Life insurance includible in estate _____________

7. Jointly-owned property (value includible in estate) _____________

8. 50% of value of property owned jointly with spouse _____________

9. Miscellaneous property interests _____________

10. General power of appointment _____________

11. Annuities, death benefits _____________

12. Gift tax paid on gifts within last 3 years _____________

TOTAL:______________________

1. Mortgages payable

2. Bank loans

3. Insurance policy loans

4. Debts, etc.

TOTAL:_____________________

NET CURRENT ESTATE: _____________________