Date:

Complete the following to the best of you knowledge -- only answer those questions which apply.

1. Full Name:

2. Date of Birth:

3. Social Security Number:

4. Place of Birth:

5. U.S. Citizen: Yes  No

6. Other Names Known By:

7. Home Address:

8. E-mail Address:

9. Home Telephone Number:

10. Work Telephone Number:

11. Cellular Telephone Number:

12. Other Residences:       

13. Illinois Resident Since:

14. Are You Presently Employed?  Yes  No

15. For How Long:

16. Occupation (former if retired):

17. Employer:

18. Name of Spouse:

19. Spouse's Date of Birth:

20. Spouse's Social Security Number:

21. Spouse's Place of Birth:

22. Is Spouse a U.S. Citizen: Yes No

23. Spouse's Occupation:

24. Spouse's employer:

25. Date of Marriage:

26. Where living when married:

27. Prior Marriages: Yourself: Yes No     Spouse: Yes  No

28. Name of children of present marriage, whether natural or adopted:

A. Date of birth:

Address:

Grandchildren:

B. Date of birth:

Address:

Grandchildren:

C. Date of birth:

Address:

Grandchildren:

D. Date of birth:

Address:

Grandchildren:

E. Date of birth:

Address:

Grandchildren:

29. Name of children of prior marriage (indicate whether husband's or wife's):

A. Date of birth:

Name of child's spouse (If any):

Address:

Grandchildren:

B. Date of birth:

Name of child's spouse (If any):

Address:

Grandchildren:

C. Date of birth:

Name of child's spouse (If any):

Address:

Grandchildren:

30. Do you have any other relatives dependent upon you for support?             Yes No (If yes, give names and relationships)

31. Names and addresses of other or alternative persons to receive property:

32. Please list any specific items or amounts that you wish to give to any individuals or organizations:

                        NAME                                                  GIFT

33. All other tangible personal property (automobiles, clothing, furniture, pictures, etc.) to be distributed to (check one):

Spouse; if spouse predeceased, to children equally

Children equally

Other (specify):

34.  If all living descendants are deceased at the time of your death, to whom or what institution(s)/charitable organization(s) would you wish your estate divided amongst?  (Please give names and addresses)

35. Do you have a present will: Yes No (if yes, attach a copy.)

36. Do you have any present Inter Vivos Trusts? Yes No

(If yes, attach a copy and list approximate value: $)

37. Have you ever received a substantial amount by inheritance? Yes No

If yes, when? Approximate amount: $

38.  Do you anticipate receiving an inheritance? Yes No

If yes, give approximate amount: $

39. Have you given away more than $3,000 in money or property to any person in any single year after 1976?  Yes No (If yes, list amounts by years)

40. Are you receiving or will you receive an annuity? Yes No

If yes, to whom will the payments be made?  

Is this a Life Annuity? Yes No

Will the amounts continue after your death? Yes No

For how long?

What will the amount of each payment be? $

41. Do you work for a business which has some type of plan under which your estate or the person you specify will receive benefits on your death?             Yes No Not Sure

42. Do you have a Qualified Plan? Yes No 

43. Were you ever a participant in a Qualified Plan? Yes No

44. Who will serve as your personal representative?

Each spouse for the other? Yes No   Someone else?  

Alternative (if above person(s) unable to serve):

45. Your choice to act as guardian of your minor children (if applicable):  

City and state of residence:

46. Do you have a safe deposit box? Yes No

if yes, where is it located?

Name(s) deposit box is listed under:

47. Please check any of the following states in which you have lived or acquired property while married: Arizona California Idaho Louisiana           Nevada New Mexico Texas Washington None

48. Do you own any property in a foreign country? Yes No 

49. Advisors:

                     Accountant:           

                    address:                   

                    telephone:               

                     Trust Officer:         

                     address:                   

                    telephone:               

                    Insurance agent:       

                    address:                   

                    telephone:                

                   Investment Advisor:  

                   address:                    

                    telephone:                

LIST OF ASSETS

Approximate Values

9. Life Insurance

DISCLAIMER - Completing this form does not constitute the establishment of an attorney/ client relationship.  Following the completion of this form, please contact our office for an appointment.

Law Offices of John Peter Curielli, P.C.

126 S. Northwest Hwy

Barrington, IL 60010-4608

(847) 381-7555

Email: LawOffices@Curielli.com