Personal Information
Full Name
Home Phone Number
() –
Alternate Phone Number
() –
Address
Do you already have a will?
Yes No
Are you receiving benefits from an estate or trust? If so, please provide particulars
Have you set up a trust to benefit another person? If so, please provide particulars
What is your Nationality?
Citizenship
Occupation
Place of Birth
Date of Birth
/ /
Marital Status
Date of Marriage
* Leave blank if this does not apply to you
Place of Marriage
* Leave blank if this does not apply to you
Details of any domestic contracts
Details of any divorce decrees or dissolutions
Full Name of Spouse
Nationality of Spouse
Citizenship of Spouse
Full Name(s) of ex-spouse(s)
Full Names of all children, including Address, Date of Birth and Citizenship
Full names and Addresses of any Beneficiaries
Details of any support obligations
Details of any extraordinary personal situations, eg., disability
Residence for Income Tax Purposes
Domicile ( Country of Permanent Residence ):
Name of Accountant
Name of Investment Advisor
Name of Insurance Advisor
Assets
Safety Deposit Boxes
Location
Box Number
Registered Name
Location of the key
Real Estate
Principal Address
Municipal Address
Names on title
Location of Deed
Current Market Value
$.
Encumbrances
Assessed Value
$.
Equity
Are there any other properties?
Yes No
Insuarance, Annuities, RRSP’S and Pensions
No. of Policy
Issued By
Is your spouse named as a beneficiary?
Yes No
If no, name of beneficary
Value of benefit of Estate
$.
Money on Deposit
Name of Bank
Address of Bank
Type of Account
Account No.:
Ownership
Approximate Value
$.
Are accounts jointly held with your spouse?
Yes No
Shares, Bonds, Debentures, Guaranteed Investment Certificates
Approximate value of portfolio
$.
Description including number
Acquisition Cost and Date
Current Value
$.
Physical Location
Are there any restrictions on transfer?
Are shares subject to a Purchase and Sale Agreement?
Yes No
If a purchase and sale is in force, is it funded?
Yes No
Shares in Private Companies
Name of Company
Number and type of shares
Are there any restrictions on the transfer of shares?
Are the Shares subject to any Purchase and Sale Agreements
Yes No
In relation to the Shares, if a Purchase and Sale Agreement is in force, is it funded
Yes No
* Please obtain copies of all relevant agreements
Automobiles, Boats and Recreational Vehicles
Description
Value and Ownership
Farm Machinery, Live Stock, Tools and Quotas
Heirlooms, Artwork, Plate, Jewelery, and any collections etc.
Household goods and furniture
Other Assets
Debt Including Mortgages
Please List all debts, please provide name of Creditor, Maturity date, Principal and Interest
Total Value of Debts
$.
Approximate Net value of Estate
$.
Will Instructions
Executor(s)
Relationship to you
Alternatives
Power of Attorney for Personal Care
Who would you like to appoint as your power of attorney for personal care?
If the person you appoint cannot act or will not, who would you like to appoint?
Power of Attorney for Property
Who would you like to appoint as your power of attorney for property?
