Prepared by Norman Pickell, a will and power of attorney lawyer based in Goderich, Ontario.


Please complete as much of this Form as possible by printing your answers.

DATE: _____________________________

Full Name: __________________________________________________

Full Mailing Address: (incl. Postal Code)__________________________

___________________________________________________________

Town, City or Township _____________________  County ___________

Phone #: Home ___________________    Work ____________________

Occupation ______________________________________

Age ___________    Date of Birth ____________________ 

Birth Place _________

Do you have a Spouse/Partner/Fiancé? Yes ______ No _______

If Yes, name of that person _____________________________________

Are you and your Spouse/Partner/Fiancé presently living together? 

No ____ Yes ____

If Yes, when did you start living together?

____________________________________

Are you Married to your Spouse/Partner? Yes ____ No ____

If Yes, date of marriage _____________________

If No, are you contemplating Marriage soon? Yes ____ No ____

If Yes, date of intended marriage __________________________

Married in Ontario - Yes ____ No ____ If No, where _________________

Do you have a Marriage or Domestic Contract? No ___ Yes ___

(If Yes, please bring a copy of the Contract with you to your appointment.)

Citizenship - You __________________ Your Spouse _______________

Do you have a former spouse? No ____Yes ____

If Yes, is your divorce final? Yes ____ No ____

If No, please explain ___________________________________________

____________________________________________________________

Do you have any financial obligations to your former spouse? 

No ____Yes ____

If yes, please provide details ____________________________________

____________________________________________________________

Full names of children: Date of Birth

(1) _________________________________________________________

(2) _________________________________________________________

(3) _________________________________________________________

(4) _________________________________________________________

(5) _________________________________________________________

(6) _________________________________________________________

Do you have any other dependants? No _____ Yes _____

If Yes, Details: _______________________________________________

____________________________________________________________

Types of Assets that You Have:

Life Insurance No ____Yes ____

If Yes, for each policy, Name of Company, Beneficiary, 
(and Policy # and Amount, if known)

1. _________________________________________________________

2. _________________________________________________________

3. _________________________________________________________

R.R.S.P. No ___ Yes ___

If Yes, is your spouse the beneficiary of ALL of them? 

Yes ___ No ___

With whom are your R.R.S.P.s? ______________________________

__________________________________________________________

__________________________________________________________

R.R.I.F. No _____ Yes _____

If Yes, is your spouse the beneficiary of ALL of them? Yes ___ No ___

With whom are your RRIFs ? ___________________________________

____________________________________________________________

Do you own any real estate ? No ___ Yes ___

If Yes, details ________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

Do you own at least one automobile? Yes ____ No _____

Do you own any furniture? Yes ____ No _____

Do you own any assets outside of Ontario or hold any foreign stocks?
No ___ Yes ___

If Yes, details _________________________________________________

_____________________________________________________________

Do you have any bank, trust or credit union accounts? No ____Yes ____

If Yes, where

1. __________________________________________________________

2. __________________________________________________________

3. __________________________________________________________

4. __________________________________________________________

Do you have a safety deposit box? No ___ Yes ____

If Yes, where is it? ____________________________________________

Where are the keys? 

Key # 1 _____________________________________________________

Key # 2 _____________________________________________________

Do you own shares in a private corporation? No ____ Yes ____

If Yes, details ________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

Do you have a Shareholders' Agreement in that private corporation?
No ____ Yes ____

If Yes, please bring a copy of the Agreement with you to your appointment.)

Other than what you have mentioned above, do you have any other Investments?
Yes ____ No ____

If Yes, where are the securities kept?

____________________________________________________________

What is approximate present total value of those investments?

_______________________________

What types of investments are they? (check off all that apply to you)

G.I.C.s _______

Bonds _______

Stocks _______

Other _______ details _________________________________________

____________________________________________________________

Do you have any pension(s) through your employment? 

No ____ Yes ____

If Yes, details _______________________________________________

___________________________________________________________

Do you own any assets jointly with someone other than your spouse? 

No ____ Yes ____

If Yes, what, with whom and what is to happen to those assets upon your death?

___________________________________________________________

___________________________________________________________

Do you have any assets registered in your name that are not yours but that you are 
holding in trust for someone else? 
No ____ Yes ____

If Yes, details _________________________________________________

_____________________________________________________________

Are you presently working as an Executor/Estate Trustee where the person has died, 
but the estate is not yet finished? 
No ____ Yes _____

If Yes, details _________________________________________________

_____________________________________________________________

Has someone already died leaving you money or other assets
and the estate is not yet finished?

No _______ Yes _____ If Yes, details _____________________________

_____________________________________________________________

What other types of assets do you have
that are not already included in the above topics?

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Types of Debts that You Have: (check off all that apply to you)

None ______

Mortgage(s) on house ______

Car, bank, trust, credit union loans ______

Credit Card Debt ______

Other type of debt ______ details _________________________________

_________________________________
Signature of person completing this form