Potts, Weisberg & Musil

POTTS, WEISBERG & MUSIL

Barristers and Solicitors

90 Eglinton Avenue East, Suite 206

Toronto, Ontario M4S 3B1

Telephone(416) 485-7366

Facsimile(416) 485-7368

Email:

CONFIDENTIAL ESTATE AND FINANCIAL PLANNING QUESTIONNAIRE

Date: ______

IPERSONAL AND SPOUSE INFORMATION

1. FULL NAME______

(Please circle first name used)

______

(Any other name previously used?)

2. ADDRESS______

______

(Postal Code)

3. TELEPHONEHome: ______

Business: ______

4. OCCUPATION______

______

(Social Insurance Number)

5. BIRTH DATE______

______

(Citizenship)

6. SPOUSE’S NAME/BIRTH DATE______

______

(Citizenship)

7. DATE OF MARRIAGE______

______

(Married Previously?)

8. CHILDREN FROM ANY PRIOR MARRIAGE

______

9. PLACE AND DATE OF DIVORCE ( if applicable)

______

10. SPOUSAL/ CHILD SUPPORT TO FORMER SPOUSE OR CHILD

______

11. DO YOU PRESENTLY HAVE A WILL

______

DOES YOUR SPOUSE______

IIDOMCILE INFORMATION

1. PLACE OF BIRTH______

2. PLACE OF RESIDENCE WHILE MARRIED

______

3. PLACE OF MARRIAGE______

4. DO YOU HAVE A MARRIAGE CONTRACT OR AGREEMENT

______

5. IS YOUR PRESENT RESIDENCE PERMANENT

______

IF NOT, PLEASE EXPLAIN______

IIIFAMILY INFORMATION – CHILDREN

1.______2. ______

(Full name) (Full name)

______

(Address) (Adress)

______

(Birth Date) (Birth Date)

______

(Name of Spouse) (Name of Spouse)

IIIFAMILY INFORMATION – CHILDREN (Continued)

3.______4. ______

(Full name) (Full name)

______

(Address) (Adress)

______

(Birth Date) (Birth Date)

______

(Name of Spouse) (Name of Spouse)

IVOTHER BENEFICIARIES TO BE CONSIDERED:

1.______2. ______

(Full name) (Full name)

______

(Address) (Adress)

______

(Birth Date) (Birth Date)

______

(Relationship to You) (Relationship to You)

______

(Marital Status) (Marital Status)

______

(Name of Spouse) (Name of Spouse)

IVOTHER BENEFICIARIES TO BE CONSIDERED (continued):

3.______4. ______

(Full name) (Full name)

______

(Address) (Adress)

______

(Birth Date) (Birth Date)

______

(Relationship to You) (Relationship to You)

______

(Marital Status) (Marital Status)

______

(Name of Spouse) (Name of Spouse)

Do any of the above named beneficiaries have a financial or special need now or will they have in the event of your death?

V PROPOSED EXECUTORS AND GUARDIANS

1.Proposed Executor______

2.Address______

Telephone______

3. Relationship to You______

4. Age______

1.Proposed Alternate Executor

______

2.Address______

Telephone______

3. Relationship to You______

4. Age______

V PROPOSED EXECUTORS AND GUARDIANS (continued)

1.Proposed Guardian______

2.Address______

Telephone______

3. Relationship to You______

4. Age______

1.Proposed Alternate Guardian

______

2.Address______

Telephone______

3. Relationship to You______

4. Age______

Will the Guardian (s) require funds to accomodate your children?

______

Will the children be residing outside of Ontario?

______

Will the children be residing outside of Canada?

______

VIINFORMATION ABOUT YOUR ASSETS

Please mark as N/A nay information categories not relevant to your particular circumstances

Residence

Address:______

Year Purchased______Cost when purchased______

Manner of Ownership______

(Alone, Joint Tenant, Tenant in Common)

Current Value______

Outstanding Mortgage______

(Approximate) (Maturity Date)(Interest Rate)

Prepayment Privileges ______

Is this your principal residence?

VIINFORMATION ABOUT YOUR ASSETS (continued)

Recreational Property

Address:______

Year Purchased______Cost when purchased______

Manner of Ownership______

(Alone, Joint Tenant, Tenant in Common)

Current Value______

Outstanding Mortgage______

(Approximate) (Maturity Date)(Interest Rate)

Prepayment Privileges ______

Rental (Investment) Property

Address:______

Year Purchased______Cost when purchased______

Manner of Ownership______

(Alone, Joint Tenant, Tenant in Common)

Current Value______

Outstanding Mortgage______

(Approximate) (Maturity Date)(Interest Rate)

Prepayment Privileges ______

Net Value ______Undepreciated Capital Cost ______

Farm or Business Property

Address:______

Year Purchased______Cost when purchased______

Manner of Ownership______

(Alone, Joint Tenant, Tenant in Common)

Current Value______

Outstanding Mortgage______

(Approximate) (Maturity Date)(Interst Rate)

Prepayment Privileges ______

Net Value ______Type of Farming Business ______

VIINFORMATION ABOUT YOUR ASSETS (continued)

Pension and Other Plans

Do you belong to or contribute to a company pension plan?______

Who is the beneficiary?______

Describe benefits ______

Have you contributed to the Canada Pension Plan or the Quebec Pension Plan?______

If so, for how many years? ______

Do you have a Registered Retirement Savings Plan?______

Company______Beneficiary______

Current Value of Plan ______

Do you participate in a Deferred Profit Sharing Plan?______

Company______Beneficiary______

Current Value of Plan ______

Does your spouse have any of the above plans?______

Continue on last page, if necessary.

Insurance on your life or owned by you

Name of Insurance Company______

Face Value of Policy and Policy Number ______

Type of Policy ______

Who Pays Premium ______

Beneficiary______

Who Owns Policy______

VIINFORMATION ABOUT YOUR ASSETS (continued)

Group Life Insurance

Name of insurance company______

Face Value of Policy and Policy Number ______

Type of Policy ______

Who Pays Premium ______

Beneficiary______

Investments

Stocks: approximate total value$______

Are any companies located outside Canada?______

Approximate Original cost______

Mortgages: approximate total value$______

Are any on properties outside Canada______

Bonds/Interest Bearing Securities:

approximate total values $______

Have you undergone any capital gains planning? ______

VIINFORMATION ABOUT YOUR ASSETS (continued)

Business or Professional Financial Information

Business name______

Address______

Nature or Business______

Business Structure:Proprietorship ______

Partnership ______

Limited Company ______

Limited Partnership ______

Joint Venture ______

Fiscal year end______

If incorporated, date of incorporation______

Record details of partner (s) or shareholder (s)interests below:

Name of Owners / Birth Dates / Partner Interests / Common Share / Preferred Share / Loans to Co. / Loans from Co.

Estimated Market Value of Business$______

Does this valuation include shareholder loans?______

Has a Professional valuation been made recently? ______

If yes, by whom?______

What was the valuation?______

If applicable, what was the V-day value (Dec 31, 1971) of the shares?______

Value of surplus in capital dividend account______

Are you business interests to be continued or sold in the event of your dealth?

______

If continued, by whom? ______

If sold, to whom? ______

Are you party to a buy-sell agreement? ______If so, please provide a copy

Is a purchase/sale of shares funded by life insurance?______

Do you have key man or “critical illness” insurance?

VIINFORMATION ABOUT YOUR ASSETS (continued)

Personal Use Property

Approximate total value$______

Insured Value$______

Listed personal property______

(eg. Paintings, jewelry, stamps, sculptures)

Approximate total value$______

Bank Accounts

Approximate total value$______

Are any accounts joint with right of survivorship?______

Automobile/Other vehicles

Year and Make ______Current Value______

Other Assets

Promissory Notes______

Chattel Mortgage______

Book Debts______

Annuities______

Interest in Trusts/Estates______

Expected Inheritances______

Power of Appointment______

Tax Shelter______

Are any Assets legally situate outside of Ontario?

VIINFORMATION ABOUT YOUR ASSETS (continued)

Significant Gifts made by you

In the last five years______

Have you set up any trusts?______

Do you wish to make any?______

Approximate Total Value of your Spouse’s Assets?

Have there been any gifts from you to your spouse or vice versa?

Information about your children’s assets (continue on separate page if necessary)

Information about your annual income

Salary or net commission______

Dividends______

Bonus______

Interest Income______

Stock Options______

Other______

Will this total change significantly in the future?______

Do you have any disability benefits?______

VIINFORMATION ABOUT YOUR ASSETS (continued)

Information about your spouse and children’s income

Spousea) Salary ______

b) Dividends______

c) Interest______

d) Total______

Childrena) Salary ______

b) Dividends______

c) Interest______

d) Total______

Liabilites (list bank loans and other significant debts or contingent liablilities)

Amount $______

Owed to______

Address______

Amount $______

Owed to______

Address______

VIINFORMATION ABOUT YOUR ASSETS (continued)

Preliminary Considerations – Distribution of your estate

Burial Instructions______

Do you wish to make specific bequests of personal items in your will, prior to the general division of residue? ______

If so, please describe the item and the donee to clearly identify each

Do you wish to make specific cash legacies to individuals or charities prior to the general division of residue? ______

If so, please state the amount and donee

What is to happen if a) the named beneficiary of a personal item or cash legacy does not survive you? Is the gift to go to his or her issue (if any) or simply fall back into the residue of your estate?

What is to happen if you have left a personal item to a beneficiary but at the time of your death, you do not possess it? Shall there be a substituted gift or not?

Residue

Provisions for spouse (if any) – outright distribution or spousal trust?

Provisions for children – immediate payment or hold up of capital until certain ages?

Provision for others- siblings, friends, etc.

Alternate provision if spouse and children all predecease you or die in common disaster

Do any of your proposed residuary beneficiaries require special financial or protective consideration (ie Disabled beneficiary)?

VIINFORMATION ABOUT YOUR ASSETS (continued)

Professional Advisors – Names, Addresses and Telephone nos.

Solicitor:______

Accountant:______

Investment Advisor:______

Banker:______

Insurance Broker:______

Checklist of Documentation to be Reviewed

Current Will (self and spouse)______

Employee Benefits:

Pension and Fringe benefits______

Previous Employment Benefits______

Spouse’s Employment Benefits______

A recent print-out of your Pension/Employment Benefits ______

Income Tax Return for last two years

Self______

Spouse______

Insurance policies in force, with most recent status______

Trust documents involving family members______

Brokerage Statements______