Personal Information

Full Name

 

Home Phone Number

()

 

Alternate Phone Number

()

 

Email

 

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?

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