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2002 Summit Boulevard NE, Suite 300 Atlanta, Georgia 30319Phone: 404.410.6820Fax: 888.679.3040Email: paul@pvblack.comWeb: www.pvblack.comYour Estate Planning WorksheetThe purpose of this worksheet is to get you to think through and then write down your choicesfor many of life’s biggest “what-if” questions:How will you provide for your spouse, partner, or other family members when you die?If you have children, whom do want to provide care for them if you die before they are adults?What are your preferences for end-of-life care (which you might receive when you are unable tomake your wishes known?)I know these are tough questions. Yet by completing this worksheet, you are well on your wayto answering them- and to having peace of mind knowing that you have: empowered trusted people to handle your health care and financial decisions in the eventthat you become incapacitated in the future; protected your current assets from avoidable taxation; provided for your loved ones’ future.If you put in the time to complete as much of this worksheet as you can, we can have aconversation on a higher level- one that gradually moves from the big picture to the finestdetails. This is only possible if you take the time to review this material, complete your estateplanning worksheet, and bring your questions to our initial meeting.Most people have lots of questions as they work through this material. That’s a good thing. Ifyou find that something doesn’t apply to you, just write “N/A” and keep moving.I welcome your questions, and I look forward to meeting with you!Paul

The Law Office of Paul Black, LLCYour Estate Planning WorksheetContentsYOUR CONTACT INFORMATION & FAMILY INFORMATION . 3BASIC BACKGROUND QUESTIONS. 4GAUGING YOUR OVERALL GOALS . 4GUARDIANS, TRUSTEES, EXECUTORS AND ADVISORS . 5Choose Guardians for Your Minor Children: . 5Choose Your Testamentary Trustee: . 5Choose Your Executor(s) or Personal Representative(s): . 6Choosing Who Would Care For Your Pets: . 7Name Your Current Financial Advisors: . 7GIFTS and DISTRIBUTIONS . 8Choose Gifts or Stipends for Your Guardian: . 8Final Distribution of Your Assets: . 8Specific Gifts:. 8Gifts to Charities: . 8YOUR END-OF-LIFE ARRANGEMENTS . 9Medical & Financial Decisions If You Are Incapacitated: . 9Your End-Of-Life Healthcare Decisions . 10Your Funeral Plans . 11FINANCIAL INFORMATION . 12Your Assets & Liabilities . 12Your Retirement Benefits . 13Your Insurance Policies . 14Long-Term Care Insurance . 14Calculate the Approximate Value of Your Estate. 15Design Trust Distributions for Your Children . 15DOCUMENTS & INFO TO BRING TO OUR FIRST MEETING . 16How I Use This Form . 17Your Responsibilities . 172

The Law Office of Paul Black, LLCYour Estate Planning WorksheetYOUR CONTACT INFORMATION & FAMILY INFORMATIONClient 1:Client 2:Address:City: , GAPhone Nos. Home: Fax:Client 1 Cell: Client 2 Cell:E-mail:Client 1 Email:Client 2 Email:Client 1 Employer: Phone No.Client 2 Employer: Phone No.Children:Name: Birthdate:Name: Birthdate:Name: Birthdate:Name: Birthdate:Name: Birthdate:Client 1’s Family:Father:Client 2’s Family:Mother:Siblings:3

The Law Office of Paul Black, LLCYour Estate Planning WorksheetBASIC BACKGROUND QUESTIONSDo you have stock options? Yes NoDo you have a current Will or Trust? Yes NoDo you have interests in any partnerships? Yes NoDo you currently receive income from a trust? Yes NoAre you involved in litigation? Yes NoDo you expect to inherit in the next six months? Yes NoDo you own any copyrights, patents or trademarks? Yes NoDo you own your own business? Yes NoDo you have any deceased children? Yes NoIf you are married:Are you and your spouse U.S. citizens? Yes NoDo you have a premarital or cohabitation agreement? Yes NoDo either you or your spouse have a prior marriage? Yes NoDo either of you have children from a prior marriage? Yes NoGAUGING YOUR OVERALL GOALSOn a scale of 1 to 10 (with 10 being the highest), how highly do you value each of the followinggoals? You may have several that are of equal priority.Client 1Client 2Naming guardians & trustees for minor childrenReducing estate taxes (for sizable estates)Providing flexibility for my surviving spouseProtecting assets for my children if my spouse remarries.4

The Law Office of Paul Black, LLCYour Estate Planning WorksheetGUARDIANS, TRUSTEES, EXECUTORS AND ADVISORSChoose Guardians for Your Minor Children:If you and your spouse or partner were unable to care for your children, whom would you wantto nominate to care for your minor children? This is the person with whom your children wouldlive.Primary:Name: Relationship:Address: Phone:Age:Secondary:Name: Relationship:Address: Phone:Age:Tertiary:Name: Relationship:Address: Phone:Age:Choose Your Testamentary Trustee:If you were not around to do so, who should manage the assets for your children as they aregrowing up? (You may name the same person as both testamentary guardian and trustee if youchoose to do so. You may also name a corporate trustee like a bank trust officer.)Primary:Name: Relationship:Address: Phone:Age:Secondary:Name: Relationship:Address: Phone:Age:Tertiary:Name: Relationship:Address: Phone:Age:Do you want any trust beneficiaries to know of the existence of any trust?5

The Law Office of Paul Black, LLCYour Estate Planning WorksheetChoose Your Executor(s) or Personal Representative(s):When you die, whom do you want to manage any necessary probate proceedings for your estate?(Couples often choose each other as Primary choices, but sometimes they also agree that anotherperson- a trusted sibling- would be better able to serve). You may name any competent adult(over age 18 and not suffering from any mental incapacity) to this position.CLIENT 1:Primary:Name: Relationship:Address: Phone:Age:Secondary:Name: Relationship:Address: Phone:Age:Tertiary:Name: Relationship:Address: Phone:Age:CLIENT 2Primary:Name: Relationship:Address: Phone:Age:Secondary:Name: Relationship:Address: Phone:Age:Tertiary:Name: Relationship:Address: Phone:Age:6

The Law Office of Paul Black, LLCYour Estate Planning WorksheetChoosing Who Would Care For Your Pets:Who should care for your pets? (People will often choose the guardian of minor children iftheir children are old enough to be attached to the pets.)Name: Phone:Address:Name Your Current Financial Advisors:Accountants:Name: Phone:Company:Name: Phone:Company:Insurance Agents:Name: Phone:Company:Name: Phone:Company:Investment Advisors:Name: Phone:Company:Name: Phone:Company:If you would like the names of advisors in any of these areas, please let me know. I cannot anddo not receive any payment for referrals, but I very much like to see a team of people in place tosupport my clients.7

The Law Office of Paul Black, LLCYour Estate Planning WorksheetGIFTS and DISTRIBUTIONSChoose Gifts or Stipends for Your Guardian:Would you like to make a gift to the guardians or provide them with a stipend? This ismoney that they will use for their own needs, not the money that they will use to take care ofyour children. Ideally, the expenses directly related to raising your child would be paid forby the trust.Outright Gift to Guardian:Additional Stipend for Guardian: /monthFinal Distribution of Your Assets:If something happened to both you and your children, who should receive your assets?Specific Gifts:In your Will, do you want to make any gifts of specific items of personal property (jewelry,artwork, firearms, silver, china, other family heirlooms)?Gifts to Charities:Do you have specific charities to which you would like to contribute? (In making your listplease provide the complete name of the organization and the city and state where it isheadquartered.)8

The Law Office of Paul Black, LLCYour Estate Planning WorksheetYOUR END-OF-LIFE ARRANGEMENTSMedical & Financial Decisions If You Are Incapacitated:If you were incapacitated and needed someone to make medical and financial decisions foryou, who would that person be? Again, you can name any competent adult to this position.Client 1’s Agent for Healthcare DecisionsName: Phone:Address:Backup Agent: Name/Address/Phone:Client 1’s Agent for Financial Decisions (to hold Durable Financial Power of Attorney)Name: Phone:Address:Backup Agent: Name/Address/Phone:Client 2’s Agent for HealthcareName: Phone:Address:Backup Agent: Name/Address/Phone:Client 2’s Agent for Financial Decisions (to hold Durable Financial Power of Attorney)Name: Phone:Address:Backup Agent: Name/Address/Phone:9

The Law Office of Paul Black, LLCYour Estate Planning WorksheetYour End-Of-Life Healthcare DecisionsGeorgia law allows competent adults the right to refuse medical treatment. Please choosethe option below that best states your desires for end-of-life care. If neither does, you canattach a statement of your own to the document. The actual language used in the documentswill be more comprehensive than that presented below (this language just gives you the ideabehind each choice). You will have the opportunity to review the actual language, andamend it if you’d like, prior to signing.OPTION A: Try to extend my life for as long as possible, using all medications,machines, or other medical procedures that in reasonable medical judgment could keepme alive. If I am unable to take nutrition or fluids by mouth, then I want to receivenutrition or fluids by tube or other medical means.Client 1: Initial here if you plan to select this option.Client 2: Initial here if you plan to select this option.OPTION B: Allow my natural death to occur. I do not want any medications, machines,or other medical procedures that in reasonable medical judgment could keep me alivebut cannot cure me. I do not want to receive nutrition or fluids by tube or other medicalmeans except as needed to provide pain medication.Client 1: Initial here if you plan to select this option.Client 2: Initial here if you plan to select this option.If neither of the two choices above captures your wishes with respect to end-of-life care,Georgia law permits you to choose which forms of life support you would like to receive:OPTION C: I do not want any medications, machines, or other medical procedures thatin reasonable medical judgment could keep me alive but cannot cure me, except asfollows. Initial each statement that you want to apply to option (C).(Initials) If I am unable to take nutrition by mouth, I want to receivenutrition by tube or other medical means.(Initials) If I am unable to take fluids by mouth, I want to receive fluidsby tube or other medical means.(Initials) If I need assistance to breathe, I want to have a ventilator used.(Initials) If my heart or pulse has stopped, I want to have cardiopulmonaryresuscitation (CPR) used.10

The Law Office of Paul Black, LLCYour Estate Planning WorksheetYour Funeral PlansClient 1: I prefer: Burial CremationSpecial Instructions:Client 2: I prefer: Burial CremationSpecial Instructions:11

The Law Office of Paul Black, LLCYour Estate Planning WorksheetFINANCIAL INFORMATIONYour Assets & Liabilities: If any of these assets are held in a trust, please note so.Otherwise, simply place the value of each asset under the appropriate column.ASSETS (For each, pleaseestimate the Current FairMarket Value.)Principal ResidenceI Clie t ’s Na eI Clie t ’s Na eOther Real EstateChecking AccountsSavings Account(s)Certificates of DepositBrokerage AccountsOther SecuritiesBusiness InterestsNotes ReceivablePersonal Effects &FurnishingsAutomobiles & OtherVehiclesTOTAL ASSETSLIABILITIES:Home MortgageOther MortgagesOther LoansTOTAL LIABILITIES:Assets - Liabilities NET ASSETS:12Owned Jointly