KARA H. DALEY

ATTORNEY AT LAW

1717 NW Grant Ave, Corvallis, Oregon 97330, (541) 738-2445

CONFIDENTIAL FAMILY INFORMATION SHEET

Date:

Your Full Legal Name:

Residence Address:

Residence Phone:	Business Phone:

Marital Status: □ Single □ Married □ Divorced □ Widow / Widower Year married:

Do you have a Prenuptial Agreement in effect?

Do you want you and your spouse to be jointly represented by this firm?

Husband	Wife
Full Legal Name
Former/Other Name
Form of Address	Mr. Dr. Rev.	Miss. Ms. Mrs. Dr. Rev.
SS No.
Birthdate
Birthplace
Citizenship
Occupation

FORMER MARRIAGE(S)
Former Spouse Name
S.S. No. of Former Spouse
Date of Marriage
Date of Divorce
Copy of Dissolution Papers	□ Provided to attorney

□ I do not have a copy

□ I will get a copy & provide	□ Provided to attorney

□ I do not have a copy

□ I will get a copy & provide	□ Provided to attorney

□ I do not have a copy

□ I will get a copy & provide

CHILDREN OF THIS MARRIAGE (including adopted children)
Name:	DOB:
Name:	DOB:
Name:	DOB:
CHILDREN OF FORMER MARRIAGE(S)
Name:	Parents:	DOB:
Name:	Parents:	DOB:
Name:	Parents:	DOB:
SIBLINGS/ OTHER FAMILY MEMBERS	City/ State
Name:
Name:
Name:

ADVISORS
TITLE	NAME	ADDRESS	TELEPHONE
Primary Personal Bank
Life Insurance Agent
Stock Broker
Referred to our firm by

PROPERTY INFORMATION:

Real Estate:

Market	Balance of	Net

Description & Location	Ownership	Value	Mortgage	Equity

H W JT

□ □ □	$	$	$

□ □ □	$	$	$

□ □ □	$	$	$

□ □ □	$	$	$

□ □ □	$	$	$

Cash Accounts:

Ownership	Checking	Savings	CD's

Or Money

Market

Name of Institution	H W JT

□ □ □	$	$	$

□ □ □	$	$	$

□ □ □	$	$	$

□ □ □	$	$	$

□ □ □	$	$	$

Safe Deposit Box:

Safe Deposit Box: Name of Institution

Branch	Box No.:	Ownership: H □ W □ Jt □

Others listed on box:

Name:	Relationship:

Address:

Phone:

Investments: (Stocks, Bonds, etc. If held in street name with Broker, just list the Brokerage Account)

Ownership	Value

H W JT

□ □ □	$

□ □ □	$

□ □ □	$

□ □ □	$

□ □ □	$

Business Interests:	(For type use "C" for Corporation, "P" for Partnership, "LLC" for Limited Liability Company, "SP" for Sole Proprietorship)

Name of Business

H W JT	Type	% Interest	Value

C P LLC SP

□ □ □	□ □ □ □	$

□ □ □	□ □ □ □	$

□ □ □	□ □ □ □	$

□ □ □	□ □ □ □	$

Mortgages, Notes, and Other Receivables:

Ownership	Date of Note	Amount Now
Due

H W JT

□ □ □	$	$

□ □ □	$	$

□ □ □	$	$

□ □ □	$	$

Miscellaneous:	(List only major personal effects such as automobiles, valuable jewelry, paintings, coin collections, stamp collections, etc.)

Ownership	Net Value

H W JT

□ □ □	$

□ □ □	$

□ □ □	$

□ □ □	$

Life Insurance:

Alternate	Death	Policy

Company	Type	Owner Beneficiary	Beneficiary	Benefit	Loans

(Term, W/L,etc)

Retirement Benefits (Including IRA's):

Beneficiary	Present

H W	if any	Value

□ □	$	$

□ □	$	$

□ □	$	$

□ □	$	$

□ □	$	$

Estate Summary:

H	W	JT

Real Estate	$	$	$

Cash Accounts	$	$	$

Investments	$	$	$

Business Interests	$	$	$

Receivables	$	$	$

Miscellaneous	$	$	$

Life Insurance	$	$	$

Retirement Benefits	$	$	$

Other	$	$	$

TOTAL	$	$	$

We will discuss how to select Personal Representatives, Guardians, and Trustees in our meeting. Please insert your tentative choices below.

Personal Representative (carries out the terms of your will):

1st Choice:	Relationship:

Address:

Phone:	Fax:

2nd Choice:	Relationship:

Address:

Phone:	Fax:

Personal Representative (carries out the terms of your will) - Continued

3rd Choice:	Relationship:

Address:

Phone:	Fax:

Guardian / Conservator (to make decisions for you and handle your affairs if you are unable):

1st Choice:	Relationship:

Address:

Phone:	Fax:

2nd Choice:	Relationship:

Address:

Phone:	Fax:

Guardian (to care for minor children):

1st Choice:	Relationship:

Address:

Phone:	Fax:

2nd Choice:	Relationship:

Address:

Phone:	Fax:

Trustee (to manage funds for minor children or to manage funds after death of spouse):

1st Choice:	Relationship:

Address:

Phone:	Fax:

2nd Choice:	Relationship:

Address:

Phone:	Fax:

Attorney-In-Fact For Business Affairs (to handle business affairs):

1st Choice:	Relationship:

Address:

Phone:	Fax:

2nd Choice:	Relationship:

Address:

Phone:	Fax:

Health Care Representative (makes health care decisions when you are unable):

1st Choice:	Relationship:

Address:

Phone:	Fax:

2nd Choice:	Relationship:

Address:

Phone:	Fax:

Person to make decisions regarding disposition of remains (Note form requirements in ORS 97.130):

1st Choice:	Relationship:

Address:

Phone:	Fax:

2nd Choice:	Relationship:

Address:

Phone:	Fax:

Generally, to whom do you want to leave your assets:

Special Bequests (specific items you wish to give to people):

Name	Address	Phone	Item or Amount	Relationship

1)

2)

3)

Charitable Bequests (gifts you wish to make to charitable organizations):

Name of Organization	Address	Item or Amount

1)

2)

3)

Residue of Estate (list who is to receive estate after you have made your general, specific, and charitable gifts):

Person(s)	Address	Percentage

Beneficiaries (in the event of common disaster):

Person(s)	Address	Phone

Other Special Provisions Desired:

(Please go on to next page)

Important Family Questions:

1.	Do you have a child with a learning disability?	□ Yes □ No

2.	Do any of your family receive governmental support or benefits?	□ Yes □ No

3.	Do you have adopted children?	□ Yes □ No

4.	Do any of your children have special education, medical, or physical	□ Yes □ No

needs?

5.	Are any of your children institutionalized?	□ Yes □ No

6.	Are you or your spouse receiving social security, disability, or other	□ Yes □ No

governmental benefits?

7.	Do you provide primary or other major financial support to adult children?	□ Yes □ No

8.	Have either of you been divorced?	□ Yes □ No

9.	Are you making payments pursuant to a divorce or property settlement	□ Yes □ No

agreement?

10.	Have you and your spouse ever signed a pre-or post-marriage contract?	□ Yes □ No

(Please furnish a copy)

11.	Have you or your spouse been widowed? (If a federal estate tax return	□ Yes □ No

or a state death tax return was filed, please furnish a copy)

12.	In what states have you lived while married to your current spouse?	□ Yes □ No

During what periods of time did you reside there?

13.	Have you or your spouse ever filed federal or state gift tax returns?	□ Yes □ No

(Please furnish copies of these returns)

14.	Have you or your spouse completed previous wills, trusts, powers of	□ Yes □ No

attorney or other estate planning arrangements? (Please furnish copies

of these documents)

15.	Are both you and your spouse United States citizens?	□ Yes □ No

If you answered "No," are either you or your spouse a resident or a	□ Yes □ No

nonresident alien?

16.	Do you want specific funeral arrangements?	□ Yes □ No

Specify, if applicable:

Other Information or Comments:

Thank you for taking the time to fill out this form. It makes our meeting more productive.