Jacobs, Wilson & Onofry · Estate Planning, Elder Law and Real Estate

Estate Planning Worksheet

Completing this worksheet lets us design an estate plan that meets your goals. Everything you enter is strictly confidential. Answer what you can — blanks are fine, and we will fill the rest in together at your appointment. Your answers are held in this browser on your own device as you type; nothing is sent to us until you print or e-mail it. Use Print or save as PDF to produce a copy — your browser's print dialog will also let you save it as a PDF and e-mail it to Info@JWOLawyers.com, or you can mail it or simply bring it with you. If you are e-mailing it, feel free to leave the date of birth and last four digits of your Social Security number blank — we will take those from you in the office.

515 Broad Street, Milford, Pennsylvania 18337 · Phone (570) 904-2098 · Info@JWOLawyers.com · Mon–Fri 8:30 am – 4:30 pm

Our plans are drawn under Pennsylvania law. If you also own property in New York, New Jersey or another state, say so — a second state's law reaches the real estate located there.

01

Who is planning

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Relationship of the two clients

Unmarried partners have no elective share, marital deduction or intestate rights in each other, and pay Pennsylvania inheritance tax at 15% rather than 0% — it changes the design, so tell us here.

How did you hear of us / referred by

Client onePersonal information

Legal name

The name most often used to title property and accounts

Also known as

Other names used to title property and accounts

Prefers to be called

Date of birth

May be left blank if e-mailing

Last 4 of SSN

May be left blank if e-mailing

US citizen

Home address

City

State

Zip

County of residence

The Register of Wills of your county of domicile probates the will

Is this your primary residence

If domiciled elsewhere, which state

Home / cell phone

Business phone

E-mail

Employer

Position

Business address

Date of marriage (if any)

Date of divorce (if any)

Prior spouse deceased — date

Client twoPersonal information

Legal name

The name most often used to title property and accounts

Also known as

Other names used to title property and accounts

Prefers to be called

Date of birth

May be left blank if e-mailing

Last 4 of SSN

May be left blank if e-mailing

US citizen

Home address

Leave blank if the same as client one

City

State

Zip

Home / cell phone

Business phone

E-mail

Employer

Position

Business address

Date of marriage (if any)

Date of divorce (if any)

Prior spouse deceased — date

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02

Children and other family

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Use full legal names. Under Whose, enter Both if you are both parents, C1 or C2 if only one of you is, or the relationship (brother, niece, nephew, friend) for anyone who is not a child.

Name	Birth date	Whose / relationship	Address	Phone	Disabled	Children	Their ages

Parents living — client one

Names, or "both deceased". Tell us if you do or do not intend to provide for them.

Parents living — client two

Names, or "both deceased". Tell us if you do or do not intend to provide for them.

Anyone deliberately left out, and why

Pennsylvania protects a spouse's elective share of one third, but children may be left out if that is your wish and the will says so plainly.

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03

Your advisors

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Role	Name	Telephone	Firm / e-mail
Personal attorney
Accountant
Financial advisor
Life insurance agent
Primary care physician

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04

Your concerns

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Rate each item: High, Some, Low, or N/A. Where the two of you differ, that is useful for us to know.

Concern	Client one	Client two
Getting affairs in order — a plan for death or disability
Providing for and protecting a spouse or partner
Providing for and protecting children
Providing for grandchildren, nieces or nephews
Leaving a family member out of the plan
Providing for charities at death
Transfer and survival of a family business or farm
Reducing Pennsylvania inheritance tax — 4.5% to children, 12% to siblings, 15% to others
Avoiding or reducing federal estate tax
Avoiding probate and reducing administration costs
Avoiding a guardianship proceeding during incapacity
Avoiding will contests or family disputes
Protecting assets from lawsuits or creditors
Keeping your affairs private
Planning for a beneficiary with disabilities or special needs
Protecting an inheritance from a beneficiary's divorce
Protecting an inheritance if the survivor remarries or repartners
Long-term care, nursing home costs and Medicaid planning
Keeping the family home or camp in the family
Coordinating property owned in more than one state
Not having your death prolonged by artificial means

Other concerns

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05

Important family questions

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Is either of you receiving Social Security, disability or other government benefits? Yes No

If yes, describe

Is either of you making payments under a divorce or property settlement order? Please furnish a copy. Yes No

Have you signed a pre-marital, post-marital or cohabitation agreement? Please furnish a copy. Yes No

Has either of you been widowed? If an estate or inheritance tax return was filed, please furnish a copy. Yes No

Has either of you ever filed a federal gift tax return? Yes No

Has either of you signed a prior will, trust, power of attorney or other estate planning document? Please furnish copies. Yes No

Was any prior will or trust drawn under the law of another state? Yes No

Do you support charities you wish to provide for at death? Yes No

Have you lived while married in Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington or Wisconsin? Yes No

Is either of you currently the beneficiary of anyone else's trust? Yes No

Does any child or other beneficiary have special educational, medical or physical needs? Yes No

Does any beneficiary receive government support or benefits? Yes No

Do you provide primary or major financial support to an adult child or anyone else? Yes No

Has either of you served in the armed forces? Veterans' benefits can affect long-term care planning. Yes No

Explanations for any "yes" above, and anything else we should know

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06

Real estate

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Why this section is longTitling decides where real estate goes

A will cannot override how a deed is titled. Property held by spouses as tenants by the entireties, or by anyone with a right of survivorship, passes to the survivor no matter what the will says — and Pennsylvania has no transfer-on-death deed, so real estate here either passes by survivorship, through probate, or from a trust. Under Titled as use: C1 — client one alone · C2 — client two alone · TBE — tenants by the entireties (married) · JT — joint with right of survivorship · TIC — tenants in common · Trust · LLC · ? if you are not sure. If you have the deed, bring it.

Address or description	County & state	Use	Titled as	Market value	Loan balance

Under Use: residence, second home, camp, vacant land, rental, timeshare, farm, commercial.

Do you have the deeds, or know where they are recorded

Book and page, or the county courthouse where recorded

Property in a homeowners' or property owners' association

Common in Pocono communities — name the association and any dues owed

Mineral, gas, oil or timber rights owned or leased

Note whether the rights were severed from the surface, and any royalty income

Life estates, rights of way, easements or options

Property you have already deeded to children or a trust

Give the date — transfers within five years affect Medicaid eligibility

Property you intend to buy or sell soon

Is any property rented out or producing income? Yes No

Is any property held in an LLC, partnership or corporation? Yes No

Do you want the family home or camp kept in the family rather than sold? Yes No

Notes on real estate — who should receive what, and any concerns

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07

Other property

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How to complete this sectionOwnership matters more than value

Skip any heading you own nothing under, and use the notes fields for anything that does not fit. Under Owner use: C1 — client one alone · C2 — client two alone · JT — the two of you jointly · JTO — jointly with someone else (name them) · ? — if you are not sure. Wills and trusts cannot override joint ownership or a beneficiary designation, which is why titling is the first thing we look at.

Bank and savings accounts

Checking, savings, certificates of deposit, money market. Do not list IRAs or 401(k)s here. If an account is held for the benefit of a minor, say so and name the minor.

Institution and account number	Type	Owner	Balance

Non-qualified investments — stocks, bonds, brokerage accounts

Holding or account	Account number	Owner	Value

Retirement plans

Pension, profit sharing, IRA, Roth, SEP, 401(k), 403(b). These stay in your own name during your lifetime — the beneficiary form is what carries them into the plan, so list who is named now.

Plan and institution	Type	Owner	Value	Beneficiaries now

Life insurance and annuities

Company and type	Death benefit	Whose life	Owner	Beneficiaries now

Vehicles, boats and RVs

Description, how titled, value, any loan

Furniture and personal effects

List major items separately — jewelry, collections, firearms, antiques — and a lump sum for the rest

Business interests

Description, whose interest, your ownership share, estimated value, any buy-sell agreement

Money owed to you

Debtor, date and maturity of note, who it is owed to, current balance

Anticipated inheritance, gift or lawsuit recovery

Debts other than mortgages

Credit cards, loans, medical bills, guarantees

Digital assets and online accounts

Cryptocurrency, business or photo accounts, domains — and who should have access

Other assets, and anything that did not fit above

Summary of values

For jointly held property, enter half in each column. Estimates are fine.

Assets	Client one	Client two	Total
Real estate
Furniture and personal effects
Vehicles, boats and RVs
Bank and savings accounts
Stocks, bonds and brokerage
Life insurance and annuities
Retirement plans
Business interests
Money owed to you
Anticipated inheritance
Other assets
Less debts
Total

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08

People to act for you

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Guardian for minor children — in order of preference

Name, address, relationship

Executor of the will — and alternates

Name, address, relationship, in order. An out-of-state executor can serve in Pennsylvania, but tell us where they live.

Trustee of client one's trust — and alternates

You will normally be trustee of your own revocable trust. Name a first and a second alternate.

Trustee of client two's trust — and alternates

You will normally be trustee of your own revocable trust. Name a first and a second alternate.

Do you want a different trustee to serve during a lifetime disability than the one who serves at death? Yes No

Financial power of attorney — client one's agent

Name, relationship, any instructions or limits. Pennsylvania powers of attorney are signed before two witnesses and a notary.

Financial power of attorney — client two's agent

Name, relationship, any instructions or limits

Should your financial agent have authority to make gifts, including gifts to themselves? Yes No

Should your agent be able to create or fund a trust, or do Medicaid planning on your behalf? Yes No

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09

Health care, living will and HIPAA

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In Pennsylvania these are two parts of one advance health care directive: a health care power of attorney, naming the agent who speaks for you, and a living will, saying what you want done if you are at end of life or permanently unconscious.

Health care agent — client one

Name, relationship, any instructions. Name alternates too.

Health care agent — client two

Name, relationship, any instructions. Name alternates too.

Authorize your health care agent to take whatever steps are necessary to keep you in a personal residence rather than a nursing home? Yes No

On certification by two physicians of a need for psychological or substance treatment, may your agent arrange a voluntary admission? Yes No

Living will — provide that the moment of your death not be unnecessarily prolonged by artificial means? Yes No

Should tube feeding and artificial hydration be withheld in those circumstances? Yes No

Make your organs and tissues available for transplant? Yes No

Do you have religious or personal directions your agent and physicians should follow? Yes No

If yes, describe

While one of you is incapacitated, the trustee should give primary consideration to

the disabled client's needs first the disabled client and the other client, then others the disabled client and others equally

Who should have access to your protected health information (HIPAA)

Should access be limited, so each person named can see only what their role requires? Yes No

Should the HIPAA authorization last more than one year after death? Yes No

If yes, for how long

Disposition of remains — agent for client one

Who controls funeral and burial decisions, plus any wishes

Disposition of remains — agent for client two

Burial, cremation or pre-paid funeral arrangements already made

Funeral home, cemetery plot, pre-need contract or burial reserve

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10

How your assets should be distributed

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A share can pass outright to a beneficiary, or stay in further trust — to keep an inheritance separate from a beneficiary's own assets and creditors, to protect a beneficiary who receives or may need government benefits, or to hold a young beneficiary's share until an age you choose. We also use per stirpes: a deceased beneficiary's share drops to that person's children before passing to anyone else.

Should personal property be distributed by a written list you prepare later (a personal property memorandum)? Yes No

Specific gifts of personal property, and who gets what is not on the list

Client one's planWhere the estate goes

partner or spouse first, then my children partner or spouse takes a set amount or percentage, then my children my children, in equal shares my children, by percentage my siblings, nieces and nephews charity other — set out below

Percentages, ages and any conditions

For example: half to each son, each share in its own trust, one-third at 25 / one-half at 30 / balance at 35.

Client two's planWhere the estate goes

partner or spouse first, then my children partner or spouse takes a set amount or percentage, then my beneficiaries my children, in equal shares my children, by percentage my siblings, nieces and nephews charity other — set out below

Percentages, ages and any conditions

For example: one-third to my brother and one-third to each niece, each share in its own trust.

Should any share be held in a supplemental needs trust, or in a creditor-protected lifetime trust?

Name the beneficiary and the reason — benefits, a creditor problem, a shaky marriage, an addiction, or simply prudence.

If no one named above survives, your property should pass to

each client's own heirs-at-law half to each client's heirs-at-law the individuals or charities named below

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11

Long-term care and Medicaid

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Answer this section if either of you is over sixty-five, has a health concern, or simply wants to plan ahead. Pennsylvania Medicaid looks back five years at gifts and transfers, so dates matter more than amounts.

Does either of you now need help with bathing, dressing, meals, medication or driving? Yes No

Is either of you living in, or on a waiting list for, a personal care home, assisted living or nursing facility? Yes No

Has either of you been diagnosed with dementia, Alzheimer's, Parkinson's or another progressive condition? Yes No

Do you have long-term care insurance? Yes No

Have you made gifts or transferred property — including adding a name to a deed or account — in the last five years? Yes No

Is either of you receiving, or applying for, Medicaid, a Medicaid waiver or veterans' benefits? Yes No

Does a family member provide care that you would like to compensate? Yes No

Is protecting the home from a nursing home lien or estate recovery a priority? Yes No

Gifts and transfers in the last five years

What, to whom, when, and approximate value

Long-term care insurance details

Company, daily benefit, benefit period, inflation rider

Current monthly income

Social Security, pension, annuity, rental income — for each of you

Current care costs, and who pays them

Where you would want to be cared for, if a choice were possible

Anything else about health or care we should know

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12

Special needs planning

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Complete this section only if a child, grandchild or other beneficiary has a disability or may need government benefits. Money left directly to someone receiving SSI or Medicaid can disqualify them — a supplemental needs trust avoids that.

Beneficiary with a disability — name and relationship

Nature of the disability, and age of onset

Does this person receive SSI, SSDI, Medicaid, a waiver program or Section 8 housing? Yes No

Is there a guardian of the person or estate, or is one expected to be needed? Yes No

Is there already a supplemental needs trust or ABLE account? Yes No

Do other family members intend to leave this person money or property? Yes No

Should this person's share be equal to the other beneficiaries' shares? Yes No

Where does this person live now, and with whom

Who cares for them now, and who should after you

Trustee for the supplemental needs trust, and alternates

Often a family member with a professional co-trustee

What should happen to anything left in the trust at their death

Current benefits, case worker or agency contacts

Anything a future trustee should know — routines, preferences, therapies

This becomes the basis of a letter of intent

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13

Anything else

Step 13 of 13

Other items you want included, or want to discuss with us

Completed by

Date

Appointment date, if scheduled

All information provided is strictly confidential and does not by itself create an attorney-client relationship. Return the completed worksheet to our office before your appointment — save it as a PDF from the print dialog and e-mail it to Info@JWOLawyers.com, mail it to 515 Broad Street, Milford, Pennsylvania 18337, or simply bring it with you. If you e-mail it, you may leave the date of birth and last four SSN digits blank.

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