Retirement or IRA Accounts, Annuities, and Other
Pension Benefits:
1. Name of Company or
Custodian/Broker:__________________________________________________
Owner:_______________________ Account Number:____________________________________
Current Amount Vested or
Value of Account: $_________________________________________
Primary
Beneficiary(ies):___________________________________________________________
Contingent
Beneficiary(ies):_________________________________________________________
2. Name of Company or
Custodian/Broker:__________________________________________________
Owner:_______________________ Account Number:____________________________________
Current Amount Vested or
Value of Account: $_________________________________________
Primary
Beneficiary(ies):___________________________________________________________
Contingent
Beneficiary(ies):_________________________________________________________
3. Name of Company or
Custodian/Broker:__________________________________________________
Current Amount Vested or
Value of Account: $_________________________________________
Primary
Beneficiary(ies):___________________________________________________________
Contingent
Beneficiary(ies):_________________________________________________________
Real Estate Properties: Please give a general description of real estate (acreage, timberland, farm, pasture, commercial, rentals, etc.) owned by you and/or your spouse, if applicable, including County where located -- remember your home and any second home or beach timeshare/rental (it will be most helpful if you can also provide copies of your deeds):
Your Separate Properties:______________________________________________________________
________________________________________________________________________________
Spouse’s Separate Properties:____________________________________________________________
________________________________________________________________________________
Jointly-Held Properties:_________________________________________________________________
________________________________________________________________________________
Summary of Business Interests:
(For each business in which you or your spouse own an interest, please also complete the attached "Closely Held Business Interests" form that you will find at the end of this checklist):
Name
Type and Percentage Kind
of
Value of Your
of
of
Ownership
Business
Interest
Business Entity
Interest Activity (estimated)
1.
____________________________________________________________________________________
___________________________________________________________________________________
2.
___________________________________________________________________________________
___________________________________________________________________________________
3. ____________________________________________________________________________________
____________________________________________________________________________________
4.
____________________________________________________________________________________
____________________________________________________________________________________