KATZMAN LOGAN HALPER & BENNETT 9000 PLAINFIELD ROAD CINCINNATI

KATZMAN, LOGAN, HALPER & BENNETT

KATZMAN, LOGAN, HALPER & BENNETT

9000 Plainfield Road

Cincinnati, Ohio 45236

(513) 793-4400

PERSONAL INFORMATION WORKSHEET

CLIENT’S ESTATE PLANNING CONFIDENTIAL

PERSONAL INFORMATION:

Name: __________________________________________________________

Address: _____________________________ Telephone: ______________

Street

_____________________________________ ________________

City State Zip County

Birth Date: ________________ Age: __________ SSN: ________________

Business Occupation: ______________________________________________

Bus. Address: _________________________ Telephone: _____________

Street

___________________________________________________

City State Zip

Fill in the following if you are married:

Spouse’s Name: ____________________ If deceased, date of death: ________

Spouse’s Social Security Number: ____________________________________

Spouse’s Date of Birth:______________________________________

Spouse’s Business Occupation, if any: _________________________________

Bus. Address: _________________________ Telephone: _____________

Street

___________________________________________________

City State Zip

Date of Marriage: _____________ Place of Marriage: ________________

Any previous marriages for either spouse? Yes: ___ No: ___ If yes, answer the following:

Husband: _________________ How ended? ___________ Date: _________

Wife: ____________________ How ended? ___________ Date: _________

Fill in the following if you have children:

Name Birth Date Age If married, spouse’s name & address

______________ ________ ___ ________________________________

Do you have any children who have died, leaving descendants (your grandchildren) surviving? Yes _____ No _____ (If yes, fill in name of deceased child(ren) and names and birth dates of grandchildren who survive on reverse side of this page).

Do you have an existing Will? Yes _____ No _____ If yes, where is Will? ______________________________________ (A copy would be of aid to us).

If married, answer:

Does Spouse have existing Will? Yes _____ No _____ If yes, where is Will? ________________________________________________________________

Do you have a Safe Deposit Box? Yes _____ No _____ If yes, where? ________________________________________________________________

Do you have an accountant? If so, name and address: ____________________

________________________________________________________________

Do you wish to include charitable contributions to your church, educational institutions, etc? Yes _____ No _____ If yes, explain: _______________

________________________________________________________________________________________________________________________________

Do you or any member of your family anticipate an inheritance of any property in the foreseeable future: Yes _____ No _____ If yes, give details: __________

________________________________________________________________________________________________________________________________________________________________________________________________

Please list by full names all people (other than family members shown on Page 2) and organizations you wish included in your Will.

Name Address Age Relationship, if any

______________ ___________________ ___ _____________________

______________ ___________________ ___ _____________________

______________ ___________________ ___ _____________________

INVENTORY OF ASSETS

1) REAL ESTATE: Any owned? Yes _____ No _____ If yes, list below. Please bring in Deeds to all property you own.

Property #1 Property #2

(If this is your home, check here _____

and list it in the column)

Address: _________________________ __________________________

Owner(s) of property: _______________ __________________________

(Exact way of title

to property shown _______________ __________________________

on Deed)

_______________ __________________________

Present market value _______________ __________________________

Annual net rental __________________ __________________________

income, if any

If additional real estate is owned, check here _____ and list on additional pages attached.

2) STOCKS, BONDS & NOTES (for Federal Bonds, see Item #4)

Any owned? Yes _____ No _____ If yes, list:

# of Shares Current Market Value

Name or Face Owner(s) of Stock Per Share Total

______________ _________ ________________ __________________

If additional stock are owned, check here _____ and list on additional pages attached.

3) BANK ACCOUNTS: Do you have any? Yes _____ No _____ If yes, list:

Bank Account # Owner(s) of Account Approx. Balance

a) Savings:

___________________ _________ ________________ _____________

b) Checking: (use average balances)

___________________ _________ ________________ _____________

4) GOVERNMENT BONDS: Do you have any? Yes _____ No _____ If yes, list:

Approximate

Number of Bonds Owner(s) of Bonds Current Market Value

Series E: _____________ ______________ _____________________

Series H: _____________ ______________ _____________________

Other: _____________ ______________ _____________________

5) IRA, PROFIT SHARING OR PENSION PLAN: Yes _____ No _____

IRA Profit Sharing or Pension Plan

Name of Company ____________________ __________________________

Type of Program _____________________ __________________________

Present Market Value _________________ __________________________

6) LIFE INSURANCE: Do you have Life Insurance on your life? Yes _____

No _____ If you have Life Insurance on your life, please complete the following:

Policy Number/ Primary Contingent

Insurance Co._ Owner Beneficiary Beneficiary

a) _____________ _________ ______________ _______________