Estate Planning Form

Estate Planning/Asset Protection Form:
Please print and complete this form and return it to the Law Offices of Elaine Esther Lukic, LLC at:

Mailing address:
Post Office Box 9038
1905 B Airport Road
Breckenridge, CO 80424

Summit County: (970) 453-4788
Eagle County: (970) 476-0268
Fax: (970) 453-4580
Email: Elainelukic@aol.com
Website: www.denverattorney.net

Please provide the following information about yourself:
Full Name:
Date of Birth:
Social Security Number:
Address:
Your profession:
Cell Phone Number:
Home Phone Number:
Work phone Number:
E-mail address:
Mailing address:

1. Please provide full name, mailing address, date of birth, social security number, phone number, and relationship for yourself, husband or wife, fiancé, children and spouses of children, grandchildren, beneficiaries under your will, persons you would like to be guardian and successor guardian of any minor children, person you would like to act as your trustee, successor trustee, personal representative, agent under your power of attorney, and any business partners:

Name	Address	Date of Birth	SS#	Phone #	Relationship to Yourself

2. Medical Durable Power of Attorney:
Agent:
Successor Agent:
Your definition of "quality of life":

Your feelings about long term care/hospice and establishment of such as your residence if necessary:

Your feelings about living with family instead of a long term care facility:

Your preference concerning receiving care at the end of your life, in a hospital or hospice or at home:

Who you want to be near your bedside at the end of your life?

Do you currently have a living will?

Does this document revoke your current living will?

Do you want to reserve the right to revoke your agent's authority orally or in writing?

Before disinterested witnesses?

Do you want your agent to be reimbursed for out of pocket expenses on your behalf?

Paid a salary?

3. General Durable Power of Attorney
Who would you like to act as your agent?

Who would you like to act as your successor agent?

Any specific powers you would like to state for them (i.e., business partner may need the ability to sign business checks if you are unavailable, or to make business decisions)

4. Living Will
Please check one:
	Artificial nourishment shall not be continued when it is the only procedure being provided.
	Artificial nourishment shall be continued for ____days when it is the only procedure being provided.
	Artificial nourishment shall be continued when it is the only procedure being provided.

5. Will

Who do you want to be your personal representative?

Who do you want to be your successor/alternate personal representative?

Do you want them to act as co-PR with a corporate PR, such as a bank?

Do you have any corporations/trust companies in mind to act as co-personal representative?

Whom do you choose to act as guardian for any minor children?

Whom do you choose to act as successor guardian for any minor children?

Do you have specific items/personal gifts that you would like to make?

Any monetary gifts of money?

Any life estates (ability of specified beneficiary to use i.e. real estate for their lifetime, with actual real estate passing to "remainderman" who may be grandchildren, a charity, etc?

Do you want a trust established to pay expenses of the life estate, or should life tenant pay his own expenses?

Do you have a current will? If so, provide copy.

6. Revocable Living Trust/Testamentary Trust
Do you have children from prior marriages?

Does your spouse/fiancé have any separate property, pending lawsuits, creditor claims or potential for such?

Do you want your beneficiaries to receive your assets outright immediately, or, with minor children, do you want them to receive specified percentages or funds at various ages, i.e., 1/3 at age 18 for college costs, 1/3 at age 25 or upon graduation, balance at age 30?

Please list assets and approximate current market values, as well as cost:
	Ownership by client	Jointly owned	Owned by spouse
Bank Accounts:
Bonds, Treasuries:
Individual stocks:
Mutual funds:
IRAs:
Business Interests:
Incorporated Non-incorporated Partnerships
Real Estate:
Primary home (list any mortgage) Other real estate:
Life Insurance:
Death benefit (list beneficiaries)
Do you expect to receive any inheritance?
TOTALS:
Resident state: Health: good, fair or poor, for both husband and wife.

Have you made any gifts over $11,000?

Do you have general power of attorney or are you a trustee or beneficiary of anyone's assets or trust?

Do you have high exposure to credit claims, i.e., medical profession or high income?

Please provide copies of any deeds to real estate so that we can retitle them via Quit Claim Deeds into your Revocable Living Trust.

Do you have any pre or post nuptial agreements, child support or custody agreements, divorce decree stating the above? Please provide copies.

Were you married in a community property state, or did you acquire your assets since marriage in a community property state?

What are your primary concerns in estate planning, i.e., minimizing federal and state estate tax and probate publicity and expense, providing for continuity of your affairs should you become incapacitated, credit claims and exposure to lawsuits, etc:?