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Blazek & Gregg, PC, LLO Rev. 2/2008

BLAZEK & GREGG, P.C., L.L.O. Preserve what you have, Protect those you love, Inspire for Generations

11580 West Dodge Road, Omaha, NE 68154

(402) 496-3432 · Toll Free (888) 496-3432 · Fax (402) 496-4519

Blazek and Associates, P.C., L.L.O. is only responsible for funding the assets I/we list on this worksheet. Funding of assets not described herein or subsequently acquired will be charged for separately.

ASSET CHECKLIST

CLIENT(S) NAME:___________________________________________________________________________________________________ DUE DATE FOR FUNDING WORKSHEET____________________________________________________________________ YOU MUST REMEMBER TO PROVIDE US WITH:

o Complete Addresses and Account Numbers for all accounts o Copies of Real Estate Deeds - (Additional Fees will result for funding Out-of-State Deeds) o Homeowners Insurance Policy Number and Carrier Information o Originals of: CD’s, Bonds, and Stock Certificates o For Private Companies: Partnership Agreements including Stock Ledger and Certificates

SUMMARY OF FUNDING PROCESS: ~ Upon receiving all of the above information, we will prepare the real estate deeds and instruction letters to the appropriate companies to change title or beneficiaries and mail them to you, our client, for your review and signatures. You are then responsible for returning this paperwork to our office. ~ After we receive the signed paperwork back from you, we will file the deeds and forward paperwork to the companies. We request the companies to return verification to our office, but due to privacy policies, they may send it directly to you. If this happens, please let us know. WE HAVE NO CONTROL OVER TIMEFRAMES OF CLIENTS PROVIDING COMPLETE INFORMATION, NOR DO WE HAVE ANY CONTROL OVER THE TIME FRAMES OF TRANSFER AGENTS ACTING AND SENDING VERIFICATION ONCE THEY RECEIVE OUR REQUEST. THE ENTIRE PROCESS MAY TAKE UP TO 6-12 MONTHS TO FULLY COMPLETE & IN EXTREME CASES, MAY TAKE LONGER.


FUNDING WORKSHEET This checklist is designed to help you list all the property you own, how it is titled, and what it is worth. You may own more property than can be listed on this checklist. If so, use extra sheets of paper to list your additional property, using the same format. If there are any documents that need to be brought to the office, there will be a list at the bottom of each page for each kind of document you will need to bring in for the change of title. Remember, having these documents is essential in transferring property to your living trust. How you own your property is extremely important for purposes of properly designing and implementing your living trust-centered plan. For each property category, there is a column titled “Owner.” When filling in this column, use the following abbreviations: If you are single and you own property in your name only, use I If you are married and property is owned in the husband’s name, use H For property owned in the wife’s name, use W For property owned in joint tenancy with a spouse, use JTS For property owned in joint tenancy with someone other than a spouse, use JTO For property owned in tenancy in common with a spouse, use TCS For property owned in tenancy in common with someone other than a spouse, use TCO For community property, use CP If you can’t determine how the property is owned, use ? Having complete and correct information is essential in ensuring that your trust is funded properly and as soon as possible. If you have any questions while completing this form, please feel free to call our office.

James T. Blazek and Jerrod M. Gregg

Blazek & Associates. P.C., L.L.O. 11580 West Dodge Road Omaha, Nebraska 68154

(402) 496-3432 or (888) 496-3432 (402) 496-4519 Facsimile

www.blazeklaw.com


CLIENT INFORMATION Name and Address of each Trustmaker Telephone Numbers Social Security Number Date of Birth

CHILDREN’S/BENEFICIARY’S INFORMATION

Name and Address of each Beneficiary Telephone Number Social Security Number Date of Birth


SPECIAL INSTRUCTIONS FOR MARRIED CLIENTS

Please identify any property that you view as separate property, as opposed to marital property:

Property Description

Value

Ownership “H” for Husband, “W” for Wife

All property that is not listed here will be viewed as marital property.

Blazek and Associates, PC, LLO

Rev. 2/2008

BANK ACCOUNTS & CD’s Name/Address of Bank Account # Type of Account Owner Acct. Balance

* Checking Account (CA), Savings Account (SA), Certificates of Deposit (CD). Note: If Account is in your name (or your spouse’s name) for the benefit of a minor, please specify and give minor’s name. Please bring your original Certificate(s) of Deposit


Rev. 2/2008

RETIREMENT PLANS

(List only IRA’s, 401(k)’s, Tax Deferred Annuities, Profit Sharing Plans, Pension Plans with Death Benefit, etc.) Name/Address of Company Type of Plan Account # Owner Value

* Specify if Pension (P), Profit Sharing (PS), H.R. 10, IRA, SEP, 401(K)


Rev. 2/2008

INVESTMENT ACCOUNTS

(Do Not Include Retirement Accounts, such as IRA’s, 401(k)’s or Tax Deferred Annuities) Name/Address of Brokerage Firm Account # Type of Account Owner Acct. Balance

* Specify if a money market (MM), Investment (I), Cash Management (CM), or other account that is in a street name. Note: If Account is in your name (or your spouse’s name) for the benefit of a minor, please specify and give minor’s name.


Rev. 2/2008

STOCKS (Certificates in your possession) Company Name/Address Number of Shares Owner Fair Market Value

Note: Please list all stock ownership in publicly owned corporations (stock traded on an exchange or over the counter). Stock owned in family or nonpublicly traded companies should be listed under the corporate business section; stocks held in a street name or investment account should be listed under Investment Accounts. Please provide all stock certificates that you are currently holding


Rev. 2/2008

BONDS Description (U.S. Savings Bonds, corporate, municipal, etc.)

Number of Bonds for each Series/Type Owner Face Value

Note: Please list all types and series of stocks. You do not need to list each individual U.S. Savings Bond. We will get the numbers off each bond. Please provide originals of all U.S. Savings Bonds that you own.


Rev. 2/2008

RETIREMENT PLANS

(List only IRA’s, 401(k)’s, Tax Deferred Annuities, Profit Sharing Plans, Pension Plans with Death Benefit, etc.) Name/Address of Company Type of Plan Account # Owner Value

Specify if Pension (P), Profit Sharing (PS), H.R. 10, IRA, SEP, 401(K)


Rev. 2/2008

LIFE INSURANCE POLICIES Name/Address of Company Policy # Type of Policy Owner Insured Death

Benefit

* Type of Policy: Term, Whole Life, Split Dollar, Group Life


Rev. 2/2008

ANNUITIES Name/Address of Company Contract # Tax Deferred? Y/N Owner Value


Rev. 2/2008

MORTGAGES, NOTES AND OTHER RECEIVABLES (Money Owed to You)

Name/Address of Debtor Date of Note Due Date of Note Owed to Current Balance

Please provide a copy of the Promissory Note, Written Contract, or other documents creating right to receive payment.

SOLE PROPRIETORSHIP BUSINESS AND PROFESSIONAL INTERESTS Name/Address of Business Description of Business Owner Value

Please provide evidence of title. This can include one of the following documents: balance sheet, depreciation schedule, registration or title issued by the state, bill of sale, fictitious name or trade name affidavit.


Rev. 2/2008

PARTNERSHIP INTERESTS Name/Address of Partnership General Partner Limited Partner Owner Value

Please provide the Partnership Agreement, Certificate of Partnership or any documents you signed when purchasing the partnership interest. Include any Buy/Sell Agreements.

CORPORATE BUSINESS AND PROFESSIONAL INTERESTS Name/Address of Company # of Shares Buy/Sell Agreement % Ownership Owner Value

This is for Privately owned (nonpublicly traded) companies. * Please state if a Buy/Sell Agreement exists. If stock is owned either JT or TC with someone other than spouse, please furnish name, address and relationship. Please furnish your stock certificate or minute book.


Rev. 2/2008

FARM AND RANCH INTERESTS Description (livestock, machinery, etc.) Owner Value

Please provide evidence of title. This can include one of the following documents: balance sheet, depreciation schedule, registration or title issued by the state, bill of sale, fictitious name or trade name affidavit.

OIL, GAS AND MINERAL INTERESTS

Description (lease, pooling agreement, overriding royalty, etc.) Owner Value

Please provide a copy of the lease agreement, deed, royalty agreement, farmout agreement, pooling agreement, or other agreement you signed to create your oil, gas or mineral interest.


Rev. 2/2008

REAL PROPERTY General Description and/or Address Owner Assessed Tax Value Fair Market Value Deed #1: This deed includes the Residence.

Deed #2:

Deed #3:

Deed #4:

Deed #5:

Property & Casualty Insurance Information: (Company Name, Agent’s Name, Address, Phone No. if available & Policy number.)

Please provide a copy of the last filed deed or your land contract and be sure to number them accordingly. PLEASE PROVIDE A COPY OF THE INSURANCE POLICY COVERING ALL REAL PROPERTY LISTED HERE. PLEASE NOTE: There are additional charges for preparation and filing of out-of-state deeds


Rev. 2/2008

PERSONAL EFFECTS Description Owner Value

Itemize major personal effects such as motor vehicles, boats, jewelry, collections, antiques, furs and all other valuable nonbusiness personal property. Give a lump sum value for miscellaneous, less valuable items. Please provide any registration or title issued by the state, bill of sale, or note how the item was obtained.


Rev. 2/2008

OTHER ASSETS (Any Property Not Previously Listed)

Description Owner Value

Please list all property that does not fit into any listed category. Please provide documents you signed to purchase the property, documents you received when you received the property, or any other document you have that shows you own the property.


Rev. 2/2008

ANTICIPATED INHERITANCE, GIFT OR LAWSUIT JUDGMENT

Description:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Total estimated value:$___________ Please provide copies of wills or trusts, copy of lawsuits or judgments, or any other document that evidences your anticipated interest.


Rev. 2/2008

ASSET ALLOCATION

HUSBAND WIFE $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ HUSBAND’S TOTAL ASSETS $ WIFE’S TOTAL ASSETS $

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