Personal and Family Record - Country Financial - Va life insurance policy loan

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|PERSONAL FAMILY HISTORY |

Husband / Partner

|Full Name |Social Security Number |

|Address |

|Phone Number (home) |(work) |

|Date of Birth |U.S. Citizen? Yes No |

|Employer |Annual Salary $ |

Wife / Partner

|Full Name |Social Security Number |

|Address |

|Phone Number (home) |(work) |

|Date of Birth |U.S. Citizen? Yes No |

|Employer |Annual Salary $ |

Marriage

|Maiden Name (if applicable) |Date of Marriage |Marriage Settlement Agreement |

| | |Yes No |

Previous Marriage(s)

|Name (include maiden name if applicable) |Date of Marriage |Date of Death/Divorce |Marriage Settlement Agreement |

| | | |Yes No |

|Name (include maiden name if applicable) |Date of Marriage |Date of Death/Divorce |Marriage Settlement Agreement |

| | | |Yes No |

Military Service

| |Husband / Partner |Wife / Partner |

|Service number | | |

|VA claim number | | |

|Location of discharge papers | | |

Children

|Full Name |Social Security Number |

|Address | |

|Date of Birth |Birthplace |Marital Status |

(

|Full Name |Social Security Number |

|Address | |

|Date of Birth |Birthplace |Marital Status |

(

|Full Name |Social Security Number |

|Address | |

|Date of Birth |Birthplace |Marital Status |

(

|Full Name |Social Security Number |

|Address | |

|Date of Birth |Birthplace |Marital Status |

(

|Full Name |Social Security Number |

|Address | |

|Date of Birth |Birthplace |Marital Status |

(

|Full Name |Social Security Number |

|Address | |

|Date of Birth |Birthplace |Marital Status |

(

|Full Name |Social Security Number |

|Address | |

|Date of Birth |Birthplace |Marital Status |

Grandchildren

|Full Name |Social Security Number |

|Address | |

|Date of Birth |Birthplace |Marital Status |

(

|Full Name |Social Security Number |

|Address | |

|Date of Birth |Birthplace |Marital Status |

(

|Full Name |Social Security Number |

|Address | |

|Date of Birth |Birthplace |Marital Status |

(

|Full Name |Social Security Number |

|Address | |

|Date of Birth |Birthplace |Marital Status |

(

|Full Name |Social Security Number |

|Address | |

|Date of Birth |Birthplace |Marital Status |

(

|Full Name |Social Security Number |

|Address | |

|Date of Birth |Birthplace |Marital Status |

(

|Full Name |Social Security Number |

|Address | |

|Date of Birth |Birthplace |Marital Status |

|GENERAL INFORMATION |

Social Security Benefits

|Husband / Partner |

|Wife / Partner |

Religious Memberships

|Husband / Partner |

|Wife / Partner |

Schools Attended/Degrees

|Husband / Partner |

|Wife / Partner |

Memberships

| |Husband / Partner |Wife / Partner |

|Name & address of organization | | |

|Membership number | | |

|Death benefits | | |

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|Name & address of organization | | |

|Membership number | | |

|Death benefits | | |

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|Name & address of organization | | |

|Membership number | | |

|Death benefits | | |

| | | |

|Name & address of organization | | |

|Membership number | | |

|Death benefits | | |

| | | |

|Name & address of organization | | |

|Membership number | | |

|Death benefits | | |

Tax Records

|Location of returns |

|Name & phone number of tax preparer |

Additional General Information

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| FINANCIAL INFORMATION |

|Name & phone number of investment consultant |

Marketable Securities (stocks, bonds, mutual funds)*

| |No. of Shares/ Face |Date Purchased |Cost at Purchase |Name of Purchaser |

|Name, Cusip, Rate, Maturity |Value | | | |

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*A copy of current investment statements may be included in lieu of listing each asset.

Checking Accounts

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|Name & Branch of Institution |Account No. |Name(s) on Account |

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Savings Accounts

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|Name & Branch of Institution |Account No. |Name(s) on Account |

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Safety Deposit Boxes and Safes

| | |Location of Key/Person with | |

|Location |Box No. |Combination |Box is held jointly with |

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Retirement Accounts (Pension, Profit sharing, 401(k), IRA, etc.)

| | | | | | |

| | |Account Type |Year of 100% |Name on Account | |

|Name & Branch of Institution |Account No. | |Vesting | |Beneficiary |

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Real Estate

|Location |

|Deed book volume and page |Gift/Inheritance/Purchase |

|Acquisition date |Acquisition value |

|Name(s) on deed |

|Current value |Appraised? Yes No |

|If Yes, by whom, when, and appraised value |

|Restrictions & agreements |

|Improvements |

|Insurance coverage (include name of agent) |

|Mortgage (name, address, account number, balance) |

(

|Location |

|Deed book volume and page |Gift/Inheritance/Purchase |

|Acquisition date |Acquisition value |

|Name(s) on deed |

|Current value |Appraised? Yes No |

|If Yes, by whom, when, and appraised value |

|Restrictions & agreements |

|Improvements |

|Insurance coverage (include name of agent) |

|Mortgage (name, address, account number, balance) |

(

|Location |

|Deed book volume and page |Gift/Inheritance/Purchase |

|Acquisition date |Acquisition value |

|Name(s) on deed |

|Current value |Appraised? Yes No |

|If Yes, by whom, when, and appraised value |

|Restrictions & agreements |

|Improvements |

|Insurance coverage (include name of agent) |

|Mortgage (name, address, account number, balance) |

Limited Partnerships

|Name and address |

|Investment interest |

Automobiles

|Make: |Model: |

|Year: |Title owner: |

|Make: |Model: |

|Year: |Title owner: |

|Make: |Model: |

|Year: |Title owner: |

Major Household Goods, Antiques, and Special Collections

|Item |Value Estimate |

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Jewelry and Furs

|Item |Value Estimate |

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Miscellaneous Personal Property

|Property |

|Name & address of personal property insurer |

|Does insurer have property inventory? Yes No |

|Property |

|Name & address of personal property insurer |

|Does insurer have property inventory? Yes No |

|Property |

|Name & address of personal property insurer |

|Does insurer have property inventory? Yes No |

Life Insurance, Long-Term Care Insurance, and Annuities

|Name & address of issuing company |

|Name & address of insurance agent |

|Policy owner |

|Policy number |Date issued |

|Type of policy (whole life, term) |Face value |

|Policy loan? Yes No |If Yes, when and amount? |

|Primary beneficiary |

|Secondary beneficiary |

|Location of policies |

(

|Name & address of issuing company |

|Name & address of insurance agent |

|Policy owner |

|Policy number |Date issued |

|Type of policy (whole life, term) |Face value |

|Policy loan? Yes No |If Yes, when and amount? |

|Primary beneficiary |

|Secondary beneficiary |

|Location of policies |

|Name & address of issuing company |

|Name & address of insurance agent |

|Policy owner |

|Policy number |Date issued |

|Type of policy (whole life, term) |Face value |

|Policy loan? Yes No |If Yes, when and amount? |

|Primary beneficiary |

|Secondary beneficiary |

|Location of policies |

(

|Name & address of issuing company |

|Name & address of insurance agent |

|Policy owner |

|Policy number |Date issued |

|Type of policy (whole life, term) |Face value |

|Policy loan? Yes No |If Yes, when and amount? |

|Primary beneficiary |

|Secondary beneficiary |

|Location of policies |

(

|Name & address of issuing company |

|Name & address of insurance agent |

|Policy owner |

|Policy number |Date issued |

|Type of policy (whole life, term) |Face value |

|Policy loan? Yes No |If Yes, when and amount? |

|Primary beneficiary |

|Secondary beneficiary |

|Location of policies |

Business Interests

|Name & address of business |

|Nature of interests |Fiscal year |

|Buy-Sell/Stock Purchase Agreement? Yes No |Retirement Agreement? Yes No |

|Are agreements funded? Yes No |Defined Compensation? Yes No |

Life Insurance Related to Business Interests

|Insured |

|Face amount |Purpose |

|Cash value |Location of policy |

|Insured |

|Face amount |Purpose |

|Cash value |Location of policy |

Debts - Personal

|Name, Address & Phone of Creditor |Account Number |Names on Account |Balance |

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Debts - Business

|Name, Address & Phone of Creditor |Account Number |Names on Account |Balance |

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Additional Notes:

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| ESTATE INFORMATION |

Will Information – Husband / Partner

|Date of last will |Location of will |

|Name of executor(s) |

|Name & address of attorney who prepared the will |

Power of Attorney – Husband / Partner

|Name & address of person(s) appointed |

|Location of additional copies |

|Does agent have a copy? Yes No |Power of Attorney for healthcare property |

Will Information – Wife / Partner

|Date of last will |Location of will |

|Name of executor(s) |

|Name & address of attorney who prepared the will |

Power of Attorney – Wife / Partner

|Name & address of person(s) appointed |

|Location of additional copies |

|Does agent have a copy? Yes No |Power of Attorney for healthcare property |

Living Trusts

| |Husband / Partner |Wife / Partner |

|When established | | |

| | | |

|Name & address of Trustee | | |

|Location of trust document | | |

|Attorney who prepared trust | | |

Other Trusts For Which You Are Maker, Beneficiary or Remainderman

| |Husband / Partner |Wife / Partner |

|When established | | |

|Name & address of Trustee | | |

|Beneficiaries | | |

| | | |

|Remaindermen | | |

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|Location of trust document | | |

|Attorney who prepared trust | | |

Burial and Administration Direction

|Location of cemetery or moratorium |

|Right to or title in burial lot |

|Name & address of preferred funeral director |

|Special instructions for your funeral/burial |

|Burial account |

|Name & address of preferred attorney |

|Name & address of preferred real estate agent |

|Name & address of preferred auctioneer |

Additional notes:

| |

Gifts

List all gifts valued in excess of $10,000 (or current indexed gift tax exclusion amount) that you have given within the last three years. Do not include gifts to your spouse. Update on a regular basis. Include name of custodian for UTMA accounts.

|Date of Gift |Name of Recipient |Value of Gift |

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|Have you used or claimed any portion of your Federal Unified Credit for Estate and Gift? |Yes No |

|Have you used or claimed any portion of your Federal Generation Skipping Tax Exclusion? |Yes No |

|If yes to either, provide dates, amounts, nature of transfer, and location of relevant documents. |

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Additional Comments

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|Date this booklet prepared |Date(s) modified or reviewed |

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