1. Your Full Name:

______________________________________________________ First Last

2. IF MARRIED OR SEPARATED, complete (a) and (b) below: (a) Spouse's Full Name:

______________________________________________________ First Last

3. Your Street Address: ____________________________________

City ____________________ State ____ Zip Code ______________

4. Telephone Numbers:

Cell: _____________________________________ ________________________

Day: ____________________/Night: ________________________

5. E-mail address: _______________________________________

6. Referred By: _________________________ 7. Today's Date ____________

If referred by a person, is this a client or attorney? __________________________________

Do you want a Living Will telling hospitals and doctors not to prolong your life by artificial means, i.e. Terri Schiavo; Karen Quinlan? Yes ________ No _____

Do you want a Durable Power of Attorney in the event of your physical or mental disability to help you with financial affairs? Yes ________ No ________ How can we help you? What are your questions/other important info?

______________________________________________________________

_______________________________________________________________

_______________________________________________________________ [It is required by New Jersey Court Rules that all pages be filled out in person's own handwriting prior to seeing the attorney]

8. Your Sex: [ ] Male [ ] Female

9. Your Marital Status: [ ] Single [ ] Married [ ] Separated [ ] Divorced [ ] Widowed

10. Your Date of Birth: ___________________ SS # __________________ Month Day Year

11. Spouse Date of Birth: _________________ SS # __________________ Month Day Year 12. If you are the parent or legal guardian of a minor child or minor children, please check here. [ ]

2. ESTATE EXECUTOR The person charged with administering/Probating your estate, paying taxes and/or other debts, preserving, managing, and distributing estate assets and property is called an Executor. This person should be one in whom you have trust and confidence. Your SPOUSE is usually named as primary Executor, followed by the child who lives closest to you. Please provide the following information about the person you wish to name to serve in this capacity. 1. PRIMARY Choice of Executor/Personal Representative:

Name: _______________________ _______________________ First Last

Relationship: _______________ Address: ____________________ 2. SECOND Choice of Executor: This individual will serve in the event that the primary executor/personal representative is not alive at the time of your death, or is unable to serve. Full Name: ___________________________ _________________ First Last

Relationship: _______________ Address: ____________________

The two proposed Executors must be filled out prior to meeting the attorney.

Asset Information- Must Be Completed - If none, write �none�

House/Real Estate Address _________________________________________________

Estimate Total Real Estate Value: _____________ Approx mortgage ________________

Bank Accounts, Stocks, CDs and Assets: _______________________________________

Approximate Amount _______________________________________________________

Beneficiaries of Bank Accounts (if none write "none") ______________________________

Other Major Assets (if none, write "none"): _______________________________________

Approximate Life Insurance: _________________ Beneficiary ____________________

In the Will- Who do you want to get your assets:

Beneficiary (1) _______________________ Relationship _______________

Beneficiary (2) _______________________ Relationship _______________

Beneficiary (3) _______________________ Relationship _______________

[It is required by New Jersey Court Rules that assets and beneficiaries be filled out prior to seeing the attorney]

Any Specific Bequests of Money and Property: _________________________________________________________________________ _________________________________________________________________________

[ ] A. MARRIED PERSONS WITH CHILD(REN) OR GRANDCHILD(REN). Generally most married people provide that, upon their death, property will be distributed as follows: 1. Your estate (all property and assets not owned jointly with another person) will be distributed to your surviving spouse. 2. If your spouse predeceases you, then your estate will be divided in equal shares among all of your living children, If any child shall predecease you, then that child's share to their children (grandchildren).

Names of Children: ______________________________ Age: ______

______________________________ Age: ______

______________________________ Age: ______

LIST THE NAMES AND AGES OF ALL CHILDREN EVEN IF THEY ARE OLDER THAN EIGHTEEN. IF NO CHILDREN, WRITE NONE. III. GUARDIAN(S) OF MINOR CHILD(REN) [Skip this section if you have NO minor children and DO NOT want a trust. There are substantial additional fees for preparation of a Trust] The surviving parent of a minor child is ordinarily entitled to be the GUARDIAN of that child. In the case of simultaneous death of you and your spouse, or if you are a single parent, you should appoint a Guardian for your minor child. It is advisable, prior to the completion of this Questionnaire, to make sure that your proposed Guardian(s) is (are) willing to serve as Guardian(s). In addition, the Guardian will also hold the monies for the minor children UNLESS you direct us otherwise. In your Will you can have any adult serve as Trustee of monies for minor children. Provide the following information about the person(s) you select to be Guardian(s)/Trustee(s). In the event my spouse predeceases me, I name as GUARDIAN(S)/ TRUSTEE(S):

1. PRIMARY Choice of GUARDIAN / TRUSTEE:

Full Name: _______________________________________

Relationship: ______________________________________

2. SECOND Choice of GUARDIAN / TRUSTEE:

Full Name: _______________________________________

Relationship: _____________________________________

Are there any beneficiaries with special needs, or receiving SSI or SDD? Please answer in detail ________________

[ ] B. MARRIED PERSONS WITH NO CHILD(REN) OR GRANDCHILD(REN). Generally most married people with no child(ren) or grandchild(ren) provide that upon their death their property will be distributed as follows: 1. Your estate (all property and assets not owned jointly with another person) will be distributed to your surviving spouse, but 2. If your spouse predeceases you, then your estate will be distributed to your living parent, or equally to your living parents. 3. But should both of your parents predecease you, then your estate will distributed equally to your brothers and sisters or equally to the children of a predeceased brother or sister. Please check B above only if you wish your property distributed precisely and exactly as indicated in section B, 1 through 3, above. Additional information on Wills, Probate and Elder Law available at www.njlaws.com [ ] C. DIVORCED OR WIDOWED PERSONS WITH CHILD(REN) OR GRANDCHILD(REN). Generally, most divorced or widowed persons with child(ren) or grandchild(ren) provide that upon their death property will be distributed as follows: 1. Your estate (all property and assets not owned jointly with another person) will be distributed in equal shares to all of your living child(ren). 2. But if one or more of your children predeceases you, that deceased child's share will be distributed to his or her child(ren), your grandchild(ren) in equal shares

[ ] D. ALTERNATE PLAN OF DISTRIBUTION - You may list specific gifts to individuals and/or divide your estate among several individuals by listing percentages to each, making sure that the percentages total 100%. You may add additional sheets if necessary or use the back of this form. There are additional Will preparation fees if there are gifts, called specific bequests. PLEASE WRITE DOWN ANY QUESTIONS YOU HAVE HERE or anything else important that we should be aware. Use back of this page for additional important information:

_______________________________________________________________ _______________________________________________________________ ESTATE PLANNING Your estate may be subject to Federal Estate Taxation if the total of your assets exceeds $1,500,000. If your assets exceed $1,500,000 and you desire estate planning to avoid or reduce your estate tax or require a Trust to protect a spouse, please advise Mr. Vercammen. A Standard Will is not designed to address estate tax issues. We do not do Tax Planning or Medicaid Planning.

WILLS: T 1- Parents with minor children and trust for children ____________ T 2- Parents no spouse ____________ T 3- Unmarried ____________ T 4- Parents without trust ____________ T 5- Unified Credit Trust over $1 million? ____________

PAYMENT WILL BE MADE BY: (Please circle one) Check, Credit Card (Visa, Mastercard, American Express) or Cash Payment is required for Will, Power of Attorney and other document preparation at the first consult and prior to any documents being drafted. We charge a $100.00 consultation fee, which is credited to the preparation of the Will or other document. This $100.00 fee is non-refundable even if the documents are not prepared. If there are any changes to a draft Will, Power of Attorney, or other document, there will be a minimum charge of $50 per revision. The Will needs to be signed within 20 days of initial consult or additional fee will be charged. This form was filled out by: ________________________ Revised 7/26/05, 2 Confidential Will Q Imac2 ________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

WILLS:

T 1- Parents with minor children and trust for children

T 2- Parents no spouse

T 3- Unmarried

T 4- Parents without trust

T 5- Unified Credit Trust over

Please advise us if you also want a Power of Attorney and/or a Living Will.