Client Name: Date Completed:

This questionnaire will assist your von Briesen & Roper, s.c. attorney in identifying the tax and non-tax issues

relevant to your estate plan. Estimates rather than exact figures should suffice for the financial information. If you

prefer, you may attach a recent financial statement which includes information requested in the personal financial

statement section and fill in the remaining items as needed.

Toll Free Number for all Locations: 800.622.0607

Milwaukee Office:

411 East Wisconsin Avenue, Suite 1000

Milwaukee, WI 53202

414.276.1122

Waukesha Office:

20975 Swenson Drive, Suite 400

Waukesha, WI 53186

262.241.5600

Appleton Office:

331 East Washington Street

Appleton, WI 54911

920.702.5330

Madison Office:

10 East Doty Street, Suite 900

Madison, WI 53703

608.441.0300

Oshkosh Office:

2905 Universal Street, Suite 2

Oshkosh, WI 54904

920.233.0250

Neenah Office:

224 East Doty Avenue

Neenah, WI 54945

920.729.0303

CONFIDENTIAL ESTATE PLANNING QUESTIONNAIRE FOR SINGLE PERSONS

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GENERAL DATA Personal Information

Name:

Social Security Number:

Date of Birth:

Occupation:

Employer:

Home Address:

Home Phone: Alt. Phone:

Email Address:

County of Residence: Children Attach additional sheets if needed. Indicate if deceased. Name (first, last) M / F

Date of Birth Address Spouse Name Child’s Children Names/DOB (grandchildren) Name (first, last) M / F

Date of Birth Address Spouse Name Child’s Children Names/DOB (grandchildren)

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Name (first, last) M / F

Date of Birth Address Spouse Name Child’s Children Names/DOB (grandchildren) Name (first, last) M / F

Date of Birth Address Spouse Name Child’s Children Names/DOB (grandchildren) Prior Marriages Yes No If yes, to whom: How and when marriage ended:

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ESTATE PLANNING DOCUMENTS

Indicate if you currently have in effect any of the following estate planning documents: Yes No

Will

Revocable Trust

Durable Power of Attorney for Financial Matters

Health Care Power of Attorney

Declaration to Physicians (Living Will)

Marital Property Agreement

Prenuptial Agreement

Irrevocable Life Insurance Trust

Funeral Forms

Other: Who drafted these documents: Please provide us with copies of current documents.

Do you have beneficiary designations on file for insurance policies or retirement plan benefits? Do you have a TOD (transfer on death) on any account naming a beneficiary? Do you have any accounts held jointly with anyone? If yes, to any of the above, please provide details.

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PROFESSIONAL ADVISORS Banking Advisor

Advisor Name Bank

Address City State ZIP

Phone Email

Accountant

Advisor Name Bank

Address City State ZIP

Phone Email

Investment Manager

Advisor Name Bank

Address City State ZIP

Phone Email

Investment Manager

Advisor Name Bank

Address City State ZIP

Phone Email

Stockbroker

Advisor Name Bank

Address City State ZIP

Phone Email

Insurance Agent

Advisor Name Bank

Address City State ZIP

Phone Email

Spouse’s Physician

Advisor Name Bank

Address City State ZIP

Phone Email

Spouse’s Physician

Advisor Name Bank

Address City State ZIP

Phone Email

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BACKGROUND INFORMATION Yes No 1. Have you received a substantial amount of property from an inheritance, a gift,

or as a beneficiary of a trust? If so, please describe. 2. Do you anticipate any sizeable inheritance? If so, please describe. 3. Are you or any of your children the beneficiary or trustee of a trust created under

a Will or a written trust agreement? If so, please describe. 4. Does a third party (individual or corporation) own life insurance on your life of

or do you own life insurance on the life of someone else? If so, please indicate the name of the owner, the cash value, and the face amount of the policy(ies) on the financial statement at the end of this worksheet.

5. Do you have a safe deposit box? If so, please indicate in whose name(s) it is

rented and its location: 6. Are you a United States citizen? 7. Have you made any taxable gifts or filed a gift tax return? 8. Are any of your children or grandchildren currently receiving any governmental

or state benefits due to a disability or medical need, i.e., SSI benefits?

9. Do any of your children or grandchildren have special needs that should be considered in your estate planning documents? If so, please explain:

10. Are any of your children adopted? If so, list who and the adoption date: 11. Are there any children who are living as family members but who have not been

adopted? If so, please explain: 12. Are you the owner of any Edvest Accounts and if so, have you appointed

successor owners? Please describe:

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PERSONAL REPRESENTATIVES, TRUSTEES, ATTORNEYS-IN-FACT, GUARDIANS Personal Representatives The Personal Representative is responsible for filing your Will with the Probate Court after your death, collecting all of the assets in your name which are subject to probate at your death, paying all your debts, expenses, and taxes, filing all required tax returns, and ultimately distributing your assets to your named beneficiaries pursuant to your Will. If you decide to use a Revocable Living Trust as the primary instrument in your estate plan, then there may be no probate estate in which case most of the duties traditionally performed by the Personal Representative would be performed by the Trustee(s). For this and other reasons, many people name the same person or persons, or trust company, as Personal Representatives and Trustees. You can name Co-Personal Representatives. Trustees Your Will may provide for the creation of one or more Trusts upon your death. In addition, you may decide to employ a Revocable Living Trust as the primary instrument in your estate plan, in lieu of having a Will serve as the primary instrument. In either case, it will be necessary to designate who should serve as Trustee after you die or become disabled. There is no requirement that the Trustee be a Wisconsin resident. The Trustee may be any individual over 18 years of age or a Trust Company. Initially, you can serve as Trustee of your Revocable Trust. Please keep in mind that the Trustee’s primary function is to manage and invest funds and to distribute the Trust principal and income in accordance with the Trust’s provisions. You can name Co-Trustees.

Agent for Health Care Power of Attorney Your estate planning documents will include a durable power of attorney for health care. In this document you appoint the person or persons you wish to grant authority to make health care decisions on your behalf in the event you become incapacitated. You may, but are not required to, name a successor to serve if your primary agent is unable to serve. Attorneys in Fact for Durable Power of Attorney for Financial Matters Your estate planning documents will also include a durable power of attorney granting broad powers to manage your personal matters and financial matters such as signing checks on your behalf, buying and selling property on your behalf, accessing your safe deposit box, filing tax returns for you, etc. You can name more than one person to serve as co-agents. Guardians Disregard this section if there are no minor children. If any of your children are under the age of 18, a guardianship will be necessary for each of your minor children. The Guardian(s) is (are) the person(s) with whom your minor child(ren) will live and who will be responsible for the care of the child(ren) on a day-to-day basis. The Guardian does not need to be a Wisconsin resident. If you have certain people in mind to fill these roles, please include their names, addresses and phone numbers.

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Name: Address: Phone: Name: Address: Phone: Name: Address: Phone: Name: Address: Phone: Name: Address: Phone: Name: Address: Phone: Name: Address: Phone: Name: Address: Phone:

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CLOSELY HELD BUSINESS INFORMATION Name of Company: Type of Entity: Corporation General Partnership Sole Proprietorship

C Corporation Limited Partnership Limited Liability Partnership (LLP) S Corporation Limited Liability Company (LLC) Year Business Formed or Purchased: Type of Business Conducted: Names of Owners and Percentage Owned: ( ) ( ) ( ) Gross Annual Revenue: Number of Employees: Book Value (assets less liabilities) Estimated Value of Business: Business Valuation Method: Appraisal Client Estimate CPA Buy/Sell Agreement

Estimated Growth Potential in Value of Business:

Buy-Sell Agreement: Yes No Date Prepared: Buy-Sell Fully Funded by Insurance? Estimated Annual Salary and Bonuses Paid to Owners: Type of Qualified Retirement Plan: Qualified Plan Investment Trustee: Names and Relationships of Other Family Members Involved in Business: Key Man Insurance? Disability Program? Please provide copies of the following: most recent annual minutes of directors and shareholders meetings; Buy-Sell Agreement and any amendments; most recent federal income tax return for the business; most recent balance sheet and annual income statement for business.

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PERSONAL FINANCIAL STATEMENT

Name: Date:

NOTE: It is very important to obtain accurate information regarding how assets are presently titled. The values of assets should be placed in the appropriate column. If you have a current financial statement prepared by your financial advisor, accountant, or other agent, you may attach that hereto rather than filling out the following tables.

ASSETS: $

Cash and Cash Equivalents - See Schedule A

Stocks, Bonds, Notes, Investments - See Schedule B

Real Estate - See Schedule C

Cash Value of Life Insurance and Annuities - See Schedule D

Profit Sharing Accounts - See Schedule E

Pension Accounts and IRAs - See Schedule F

Other Assets - See Schedule G

TOTAL ASSETS $

LIABILITIES:

Notes Payable - See Schedule H $

Other Debts and Accounts Payable - See Schedule I

Taxes Payable

Other Debts

TOTAL LIABILITIES $

TOTAL ASSETS $______________________ TOTAL LIABILITIES $______________________ NET WORTH $______________________ ANNUAL INCOME $______________________

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SCHEDULE A. CASH AND CASH EQUIVALENTS. SAVINGS AND CHECKING ACCOUNTS, MONEY MARKET FUNDS, C.D.s, ETC.

Name of Institution Type of Account Balance

$

TOTAL $

SCHEDULE B. STOCKS, BONDS, NOTES, INVESTMENTS.

Number of Shares Description Market Value

$

TOTAL $

SCHEDULE C. REAL ESTATE.

Description and Location Mortgages Fair Market Value

$ $

TOTAL $ $

SCHEDULE D. LIFE INSURANCE AND ANNUITIES.

Company/Policy Number Insured Beneficiary Death Benefit Cash Value

$ $

TOTAL $ $

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SCHEDULE E. PROFIT SHARING ACCOUNTS.

Company Beneficiary Approximate Balance

$

TOTAL $

SCHEDULE F. PENSION ACCOUNTS AND IRAs.

Company Beneficiary Approximate Balance

$

TOTAL $

SCHEDULE G. OTHER ASSETS: TANGIBLE PERSONAL PROPERTY, AUTOS, INTEREST IN TRUSTS, ETC.

Description Estimated Market Value

$

TOTAL $

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SCHEDULE H. NOTES PAYABLE: INCLUDE MORTGAGE BALANCES ON RESIDENCE AND OTHER REAL ESTATE.

Creditor Amount Outstanding

$

TOTAL $

SCHEDULE I. OTHER DEBTS AND ACCOUNTS PAYABLE.

Creditor Amount Outstanding

$

TOTAL $