in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits, Choice to Prolong Life I want my life to be prolonged as long as possible within the limits of generally accepted health care Confidential Financial Summary Real Estate Ownership Street Address (list home Original Current Market Equity (Market Purchase Price Value Value Less Mortgage) 1 2 3 4. Total Equity $ Asset Summary Current Estate Values for Purpose of Estimating Cost of Estate Settlement at Death, Check the assets that you own Business Assets Financial Assets Personal Assets Checking and Savings Sole Proprietorship Motor Vehicles Account Corporation _ S or _ C Boat Securities (Stocks, Limited Liability Plane Mutual Funds) Company Art and Antiquities Certificate of Deposits Limited Partnership Promissory Notes 401k , IRA or Pension Approx. Value $ Approx. Value $ Approx. $ Life Insurance and Annuities Insured Owner Cash Value Death Benefit Primary Beneficiary Contingent Beneficiary (H/W/S) (H/W/S) $ Estimate $ Paid on Death
in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits, Choice to Prolong Life I want my life to be prolonged as long as possible within the limits of generally accepted health care Confidential Financial Summary Real Estate Ownership Street Address (list home Original Purchase Price Current Market Value Equity (Market Value Less Mortgage) 1 2 3 4. Total Equity $ Asset Summary Current Estate Values for Purpose of Estimating Cost of Estate Settlement at Death, Check the assets that you own Financial Assets Business Assets Personal Assets Checking and Savings Account Securities (Stocks, Mutual Funds) Certificate of Deposits 401k , IRA or Pension Sole Proprietorship Corporation _ S or _ C Limited Liability Company Limited Partnership Motor Vehicles Boat Plane Art and Antiquities Promissory Notes Approx. Value $ Approx. Value $ Approx. $ Life Insurance and Annuities Insured (H/W/S) Owner (H/W/S) Cash Value $ Estimate Death Benefit $ Paid on Death Primary Beneficiary Contingent Beneficiary
Client%20Information%20Form%20(Single)%202018.docx