ASSESSMENT | ADS 2

CLIENT INFORMATION

1 First Name

2 Last Name

3 Address

4 Country

5 Phone

6 Email

DECEDENT INFORMATION

7 First Name

8 Middle Name

9 Last Name

10 Also Known As

11 Address

12 Country

13 Phone

14 Email

15 Citizenship

16 Social Security Number

17 Social Insurance Number

18 Other Government Insurance Number

19 Sexual Orientation

20 Marital Status

21 Nuptial Agreement

Yes

No

22 Date Married

23 Date Divorced

24 Date Widowed

25 Date of Death

26 Place of Death

27 Cause of Death

28 Describe the Death Experience

29 Did the deceased receive any hospice services?

Yes

No

30 If Yes, Where

31 Describe Hospice Services

FAMILY / HEIRS / CLOSE FRIENDS

32 Number of Members in Family

First Person

34 First Name

35 Last Name

36 Relation to Deceased

Family Member

Friend

Heir

Other

37 Date of Birth

38 Date of Death

39 State of Residence

40 Phone

41 Relationship with Deceased

Close

Conflicted

Distant

42 How Coping with Death of Deceased

PART D

135 Savings Account Name

136 Savings Account Number

137 Savings Account Balance

138 Does the deceased have any safety deposit boxes?

139 Provide a list of other active bank accounts of the deceased.

RETIREMENT ACCOUNTS

140 Short answer

141 Retirement Account Company Name

142 Account Name

143 Account Number

144 Account Type

IRA

401K

Other

145 Names of any beneficiaries

146 Provide a list of other active retirement accounts of the deceased.

147 Has any money been withdrawn without decedent's consent prior to death?

FINANCIAL ASSETS

148 Stocks owned by the deceased

149 Bonds owned by the deceased

150 Other Financial Instruments owned by the deceased

INSURANCE POLICIES

151 Name of Insurance Company

152 Type of Insurance

Life

Other

153 Policy Number

154 Estimated Value

155 Description

156 Names of Beneficiaries

157 Provide a list of any other insurance policies

POWER OF ATTORNEY

158 Was the deceased appointed by anyone as their beneficiary?

159 Did the deceased hold any power of attorneys?

160 Does a person hold Power of Attorney or serve as agent for the deceased?

161 Is there a person serving as guardian of the deceased?

LEGAL DISPUTES

162 Are there any conflicts or disputes amongst family members or heirs that may impact the estate or probate?

163 Has any other family member, heir, or person hired an attorney?