NORTHERN NEW ENGLAND CONFERENCE OF SEVENTH-DAY ADVENTISTS

FAMILY INFORMATION FORM

FILL OUT THIS FORM: Effective estate planning requires that all relevant information concerning your personal, family and financial situation be assembled. This FAMILY INFORMATION FORM is provided to aid you in organizing that information in a manner which an attorney will find useful in giving you legal advice, specific planning recommendations and in preparing documents for you. If additional space is needed for any part of this form, please include the information on a separate sheet. Thank you.

CONFIDENTIALITY: The information you give here and all resulting documents and subsequent dealings will be held in the strictest confidence and released to no one without your specific instructions to do so.

I. PERSONAL AND FAMILY INFORMATION Today's Date

You Spouse

Full Name

Father Full Name

Mother Full Name

Mother (maiden)

Home Seasonal

^{Address Address}

^{City, State, Zip City, State, Zip}

^{Phone Phone}

City Township Village

^County

^{E-mail Fax}

Date of Birth

Social Security Number

Prior Will Date(s)

Church Membership

U.S. Citizen Yes No U.S. Citizen Yes No

Living Alone Yes No Living Alone Yes No

Health

Occupation/Business

Business Address

Street Street

City, State, Zip City, State, Zip

Phone Phone

States of prior residence

Date moved to State you are presently living in

Location of personal papers

Safe Deposit Box? Yes No If yes, name and address of bank

Funeral Home Address

Cemetery/Plot Number City, State

Do you desire any special instructions to be included in the file regarding burial or cremation, anatomical gifts or extraordinary medical care? Yes No If yes, give details

YOUR ADVISORS

Name

Accountant

Broker

Insurance

Lawyer

Pastor

Phone

FAMILY STATUS

Married Separated Divorced Widowed Single

Present Marriage

^{Wedding Date City/State}

Have you had any prior marriages? Yes No. If yes, give name of your former spouse(s) and your marital status to that spouse?

Date of spouse's death Administered by Probate None

^{County and State of Administration Attorney Handling Administration}

If you are unmarried, is a marriage presently planned? Yes No. If yes, date of proposed marriage

Do you have any children from a prior marriage, or from any prior relationship, including any adopted children? Yes No. If yes, please list at the top of page 3.

Children from prior marriage/relationships: (Include adopted children)

Name Address Birth Date Parent

Living Children from current marriage: (Include stepchildren, adopted or disabled/incapacitated children and identify as such.)

Name Address Birth Date SDA? Parents: B / H / W

Deceased Children:

Name Birth Date Date of Death

Surviving children of your deceased child(ren): (Include parent's name)

Name Address Birth Date Parent

Grandchildren:

Name Address Birth Date Parent

Specify any disabilities and special needs or other instructions as to above children or grandchildren.

Other Dependents: (Include parent, spouses of children, or others you or your spouse believe to be potentially dependent on you.)

Name Address Birth Date Relationship

Siblings: (If you or your spouse have no living children or grandchildren, please list below your or your spouse's siblings.)

Name Address Relationship

(Please specify to you or your spouse.)

COMMENTS:

II. FINANCIAL INFORMATION

Estimated Personal Balance Sheet

Please complete this form by supplying your estimate of the fair market value of the categories of assets and liabilities listed below. If you have a recent personal financial statement, you may include that with this data form and complete only the retirement and insurance information.

Asset You Spouse Jointly Held

Residence (Date of Purchase ) $ $ $

Other Real Property (See Schedule)

Bank Accounts and CDs

Securities (See Schedule)

Business Interests

Life Insurance Cash Value

Receivables

IRAs

Retirement Benefits

Automobiles

Boat, Camper Etc.

Household Contents

Household Antiques

Collections:

Riding Mower and Attachments

Farm Equipment

Livestock

Total Assets $ $ $

Liabilities You Spouse Jointly Held

Real Estate Mortgages

Unpaid Taxes: Income & Property

Credit Cards

Auto Loans

Personal Signature Loans

Personal Property Loans

Other Bank Loans

Student Loans

Personal Notes Payable

Total Liabilities $ $ $

Net Worth $ $ $_______________

(Total Assets less Total Liabilities)

Value of Potential Inheritance $ $

Life Insurance Death Benefit $ $

(See Schedule)

Sub Totals $ $ $

TOTAL POTENTIAL ESTATE, INCLUDING INSURANCE AND

VALUE OF POTENTIAL INHERITANCE: $

Accidental Death Insurance $ $

Values of Assets - Estimates only. The undersigned herewith state that the values assigned to any and all assets appearing on this data form are estimates which have been determined solely and exclusively by the undersigned without the assistance of General Conference Corporation of Seventh-day Adventists, further that the said General Conference Corporation of Seventh-day Adventists or its attorney has not and will not undertake any independent investigation or study to determine the accuracy or inaccuracy of the values assigned to the various assets which are herein above disclosed.

I/we hereby verify that the above information is correct to the best of my/our knowledge.

Signed: Date:

Signed: Date:

Field Rep.: Date: