Confidential Client Profile for the use of our associated CPA and Law Firms Regular Printable Full Profile (Headquarters) Florida Office 1860 82nd Avenue Suite 206 Vero Beach FL 32966 Toll Free: (800) 922-1771 Tel: (772) 770-6680 Fax: (866) 533-4804 Nevada Office 500 N Rainbow Boulevard Suite 300 Las Vegas NV 89107 Toll Free: (800) 922-1771 Fax: (866) 533-4808 California Office 5757 W Century Boulevard Suite 700 Los Angeles CA 90045 Toll Free: (800) 922-1771 Fax: (866) 533-4808 For our comments regarding suggestions and recommendations to accomplish your estate tax, income tax and asset protection planning based on the following personal, family, financial, business situation and stated objectives, please complete and return this confidential client profile to our Office Headquarters: 1860 82nd Avenue Suite 206, Vero Beach FL 32966. Representative name Representative affiliation 1. PERSONAL FAMILY INFORMATION A. GENERAL INFORMATION Client Name Date of Birth SS# Spouse/Partner Name Date of Birth SS# Address City, State, Zip County Home Phone Home Fax Mobile: Client Mobile: Spouse/Partner E-mail Address Citizenship: Client Citizenship: Spouse/Partner Marital Status: Single Married - Date of Marriage Separated Divorced Where do you wish correspondence to be directed? Home Work Other B. EMPLOYMENT Occupation: Client Occupation: Spouse/Partner Current Employer (Client) Work Address City, State, Zip Work Phone Work Fax Work E-Mail Address Length of Employment Current Employer (Spouse/Partner) Work Address City, State, Zip Work Phone Work Fax Work E-Mail Address Length of Employment Previous Employer (Client) Address City, State, Zip Work Phone Work Fax Work E-Mail Address Length of Employment C. EDUCATION College/University Attended Address, City, State Zip Code Dates Attended Degree Earned D. CHILDREN Are there any children born or legally adopted from your PRESENT marriage? Yes No If yes, please state each child's full legal name and date of birth: Full Legal Name of Child Date of Birth E. PREVIOUS MARRIAGES Were either (or both) of you previously married? Yes No If yes, please state the full legal name of each prior spouse and the approximate date of dissolution of marriage or date of death, whichever applies, below: Name of Client's Prior Spouse/Partner Date of Divorce Date of Death Name of Spouse/Partner's Prior Partner Date of Divorce Date of Death Were any children born or legally adopted of these previous marriages? Yes No If yes, please state each child's full legal name, date of birth and child's natural parents: Name of Child Date of Birth Name of Mother Name of Father Who has legal custody? Unless you advise us otherwise, we will define "children" as meaning all children, from your current and previous marriage(s). Of all children listed, do you wish to include all as beneficiaries of your assets? Yes No If no, which do you wish to limit or exclude: Name of Child Reason for Limit or Exclusion F. HANDICAPPED CHILDREN Are any of your children or other dependents handicapped? Yes No If yes, please list name of each dependent who is handicapped and that person's handicap below: Name of Dependent Brief Description of Handicap G. GRANDCHILDREN Do you or your spouse have any grandchildren? Yes No If yes, please list names of each grandchild, their date of birth and parents: Name of Child Date of Birth Name of Mother Name of Father H. BENEFICIARIES Names of Beneficiaries DOB or SS# Relationship % of Estate I. GUARDIANS Who would you like to appoint as the guardian for your minor or handicapped children? 1st Choice: Relationship 2nd Choice: Relationship J. DURABLE POWER OF ATTORNEY FOR FINANCIAL MATTERS AND HEALTH Please list names of persons you desire to give the power to make financial and health decisions for you should you not be able to do so. Most people, if married, choose their spouse to be their Primary Agent. (Note: You may list more than one person to act for you at a time). FOR CLIENT: Primary Agent Address 1st Alternative Address 2nd Alternative Address FOR YOUR SPOUSE/PARTNER Primary Agent Address 1st Alternative Address 2nd Alternative Address K. OTHER INHERITANCES RECEIVED OR ANTICIPATED Value of Inheritance Already received Value of Inheritance Anticipated Received or Anticipated from: (Indicate source of inheritance) 2. ESTATE PLANNING GOALS AND OBJECTIVES A. FOR CLIENT: Who do you want to receive your estate and over what period of time? Most people, if married, leave their assets to their spouse if surviving and then equally to their children. You may want to consider leaving some assets directly to your children especially if they are by a former marriage. Who do you want to receive your estate if your primary beneficiaries predecease you? Most people leave their assets to their grandchildren if their spouse and/or children predecease them. Who would you like to serve as personal representative (executor) under your will? Personal Representative Successor Personal Representative Alternate Successor Who would you like to serve as successor trustee (after you) for any revocable trust established for you? Successor Trustee Alternate Successor Trustee B. FOR SPOUSE/PARTNER: Who do you want your estate divided? Most people, if married, leave their assets to their spouse if surviving and then equally to their children. You may want to consider leaving some assets directly to your children, especially if they are by a prior marriage. Who do you want to receive your estate if your primary beneficiaries predecease you? Most people leave their assets to their grandchildren if their spouse and/or children predecease them. Who would you like to serve as personal representative (executor) under your will? Personal Representative Successor Personal Representative Alternate Successor Who would you like to serve as successor trustee (after you) for any revocable trust established for you? Successor Trustee Alternate Successor Trustee C. ULTRA TRUST An Ultra Trust requires an independent trustee - someone other than yourself. Who would you like to serve as the trustee of your Ultra Trust? Relationship Successor Trustee Relationship 3. LIFE INSURANCE INFORMATION A. CLIENT Do you own any life insurance policies on your life? Yes No If yes, please fill in the following:   Policy 1 Policy 2 Policy 3 Death Benefit Amount ($) Cash Value (if applicable) ($) Who is Policy Owner? Who is Beneficiary? B. SPOUSE/PARTNER Does your spouse/partner own any life insurance policies on your life? Yes No If yes, please fill in the following:   Policy 1 Policy 2 Policy 3 Death Benefit Amount ($) Cash Value (if applicable) ($) Who is Policy Owner? Who is Beneficiary? C. CREDIT LIFE OR MORTGAGE INSURANCE Do you or your spouse/partner have any credit life, mortgage insurance or property insurance policies with life insurance benefits? Yes No If yes, please describe: Type of Insurance Amount of Insurance ($) 4. BUSINESS INTERESTS Do you own a business (s)? Yes No If your answer is yes, please list the information requested for each business below. Business # 1:  Name   Is your spouse/partner a co-owner of your business? Yes No Are there other co-owners other than your spouse/partner? Yes No If yes, list names of other co-owners Are you an officer or director of this business? Yes No Please describe the nature of this business Do you have any pension or profit sharing plan for this business? Yes No Please estimate the amount of any such pension and profit sharing plan that belongs to you ($) Please estimate the current market value for this business ($) Please indicate the estimated annual income before taxes for this business ($) Please indicate any salary or other form of compensation you receive from this business ($) Please estimate the amount of insurance premiums in the following areas: Malpractice coverage ($) Workman's Compensation coverage ($) Liability Insurance coverage ($) Other ($) Your business can be owned and operated in the following title formats. Please acknowledge which format exists for the businesses listed above. They would include the possible title formats as follows: Sole Proprietor General Partnership Professional Partnership "C" Corporation Limited Liability Company Limited Partnership Professional Corporation "S" Corporation Other (if other, please describe) Would you desire this business to be transferred to your heirs? Yes No Business # 2:  Name   Is your spouse/partner a co-owner of your business? Yes No Are there other co-owners other than your spouse/partner? Yes No If yes, list names of other co-owners Are you an officer or director of this business? Yes No Please describe the nature of this business Do you have any pension or profit sharing plan for this business? Yes No Please estimate the amount of any such pension and profit sharing plan that belongs to you ($) Please estimate the current market value for this business ($) Please indicate the estimated annual income before taxes for this business ($) Please indicate any salary or other form of compensation you receive from this business ($) Please estimate the amount of insurance premiums in the following areas: Malpractice coverage ($) Workman's Compensation coverage ($) Liability Insurance coverage ($) Other ($) Your business can be owned and operated in the following title formats. Please acknowledge which format exists for the businesses listed above. They would include the possible title formats as follows: Sole Proprietor General Partnership Professional Partnership "C" Corporation Limited Liability Company Limited Partnership Professional Corporation "S" Corporation Other (if other, please describe) Would you desire this business to be transferred to your heirs? Yes No Business # 3:  Name   Is your spouse/partner a co-owner of your business? Yes No Are there other co-owners other than your spouse/partner? Yes No If yes, list names of other co-owners Are you an officer or director of this business? Yes No Please describe the nature of this business Do you have any pension or profit sharing plan for this business? Yes No Please estimate the amount of any such pension and profit sharing plan that belongs to you ($) Please estimate the current market value for this business ($) Please indicate the estimated annual income before taxes for this business ($) Please indicate any salary or other form of compensation you receive from this business ($) Please estimate the amount of insurance premiums in the following areas: Malpractice coverage ($) Workman's Compensation coverage ($) Liability Insurance coverage ($) Other ($) Your business can be owned and operated in the following title formats. Please acknowledge which format exists for the businesses listed above. They would include the possible title formats as follows: Sole Proprietor General Partnership Professional Partnership "C" Corporation Limited Liability Company Limited Partnership Professional Corporation "S" Corporation Other (if other, please describe) Would you desire this business to be transferred to your heirs? Yes No 5. GOALS FOR ESTATE PLANNING & ASSET PROTECTION Please number your priorities for all of the following that apply to your estate planning and asset protection goals. You may also provide other goals below or, if you desire, on a separate piece of paper: Provide asset protection from creditors and lawsuits Reduce income taxes Reduce or eliminate estate taxes Avoid the expense of probate Control you assets throughout your life Provide privacy In addition to the areas indicated above, I/we have the following goals and/or objectives in planning our estate: 6. LIABILITY INFORMATION Are there any outstanding judgments against you or your spouse/partner? Yes No If yes, please give brief description: Are you and/or your spouse/partner named defendants in any current lawsuits? Yes No If yes, please give brief description: Are there any pending or potential lawsuits? Yes No If yes, please give brief description: Are you and/or your spouse/partner under a court order to prevent the transfer of assets? Yes No If yes, please give brief description: 7. INTERNATIONAL INTEREST Do you have any parents, siblings, or grandparents or close friends who are not U.S. citizens and who do not live in the U.S.? Yes No If yes, please give brief description: Are you a signer on any international bank accounts? Yes No Are you the beneficiary of, or have any interest in an international trust? Yes No Are you or member of your immediate family a beneficiary of an International Variable Life Insurance Policy? Yes No If yes to any, please give brief description: Are you an officer or director of, or have any interest in an international corporation, limited liability partnership or foreign limited liability company? Yes No If yes, please give brief description of the type of entity and the jurisdiction of such entity: Do you receive any income from offshore sources? Yes No If yes, please give brief description: 8. PREVIOUS PLANNING Do you or your spouse/partner have any of the following:   CLIENT SPOUSE/PARTNER Durable Power of Attorney (Health) Durable Power of Attorney (Assets) Living Will (year prepared ______) Will (year prepared ______) Revocable Living AB Trust Limited Partnership(s) (Family) Insurance Trust Foreign Security Trust Non US Grantor Trust Children's Trust Charitable Remainder Trust Charitable Lead Trust Pension Limited Partnership Limited Liability Company(s) Corporation(s) (International) Corporation(s) (Domestic) US Grantor International Trust Other (please list on separate paper) 9. FINANCIAL INFORMATION (Please also attach a financial statement, if available) Assets Client's Separate Spouse/Partner's Separate Joint or Community Property Cash or cash equivalents Residence Second residence Real property for investment income Investment securities Stock in closely held corporation(s) Insurance, cash surrender value Sole proprietorship(s) General partnership(s) Limited partnership investment(s) Limited liability company investments(s) Notes(s) receivable Vested interest in Pension and/or Profit Sharing Plans(s) Individual retirement account(s) Automobiles Collectibles Other assets Total assets Liabilities Mortgage(s) on residence(s) Mortgage(s) on investment income real property Secured notes payable Unsecured notes payable Other unsecured liabilities Total liabilities Net worth ($) Please give an estimate of your net income before taxes: a. From Compensation Client Spouse/Partner b. From Investments Client Spouse/Partner Joint 10. OTHER CONCERNS Please list (use a separate sheet of paper if necessary) any other issues relevant to the preparation of your analysis, any questions which you specifically wish to be addressed, or any other comments which you think may be relevant. 11. CURRENT REPRESENTATIVES AND COUNSELORS Please list the following current advisors and counselors you have: Attorney Phone # Accountant/CPA Phone # Investment Advisor Phone # Financial Planner Phone # Insurance Agent Phone # Banker Phone # Reference #1 Phone # Reference #2 Phone # Reference #3 Phone # 12. MISCELLANEOUS AREAS OF INTEREST FOR OUR LAW FIRM Are you aware of anyone who is interested in becoming a United States citizen or resident? If so, please give a brief description below: Do you know anyone who may be interested in authoring or collaborating on any subject in the legal education or business opportunity field? If so, please give a brief description below with their phone number: Would you be interested in information on how to open a foreign bank account for any of the entities or businesses that you currently have or we will recommend? Yes No 13. REFERRAL SOURCE Please remind us of how you became aware of United Wealth Protection Concepts LLC: To ensure the security of your information, we ask that you type the code (displayed below) in the text box. This code is an image that cannot be read by web robots and prevents them from gaining access to your information.