chart3.frm

The purpose of this questionnaire is to assist you to decide whether you need an Asset Protection Plan and Trust, and if so to record the information needed to prepare it. Further copies can be downloaded from http://www.rossholmes.co.nz/trusts_chart.pdf. The questionnaire has been divided into 4 parts:

1 Do I need to set up an Asset Protection Plan and Trust?	3 My wishes for the asset protection plan.
2 My details	4 My financial position

Part 1 Do I need an asset protection plan?
Disability or death risk. Do I have:
Enduring powers of attorney	☐ Yes	☐ No	Enough life assurance	☐ Yes	☐ No
Investments and loans. I am:
Buying a property in the near future:	☐ Yes	☐ No	Paying taxation at 39%	☐ Yes	☐ No
Have a good investment plan	☐ Yes	☐ No	Loss making rental properties	☐ Yes	☐ No
Relationship risks. It is important:
for me to protect assets against partners	☐ Yes	☐ No	that children’s inheritances are protected against partners and others	☐ Yes	☐ No
I am married or in a live in relationship and have been for:	years		to protect assets I owned before my relationship	☐ Yes	☐ No
Children. It is important
My children have special needs	☐ Yes	☐ No	Details:
Business and creditor risks
I have my own business now	☐ Yes	☐ No	I am likely to go into business in future	☐ Yes	☐ No
It is important to me to protect my assets against business failure, fines and being sued	☐ Yes	☐ No
Government risks: It is important to me to protect my assets against
Estate duty or capital gains tax	☐ Yes	☐ No	Geriatric care costs	☐ Yes	☐ No
Trusts and wills
I have a Trust	☐ Yes	☐ No	I have an up to date will	☐ Yes	☐ No

If you have answered most of the above questions yes, then it is important that you establish an asset protection plan including a Trust.

Part 2 My Details	Partner 1	Partner 2 (and relationship to first person
Are you married or a couple	☐ Yes ☐ No	Date of Marriage:
My full names: a. (as it is on my passport or birth certificate):
My occupation:
Street address:
Postal address:
Suburb/City and post code:
IRD numbers
Business Phone:
Mobile Phone:
Home Phone:
Email:
Fax:
Date of birth:
I have serious health problems. If yes please, give details:	☐ Yes ☐ No	☐ Yes ☐ No
My First Child: Full Names and date of birth:
My Second Child: Full Names and date of birth:
My Third Child: Full Names and date of birth:
My Fourth Child: Full Names and date of birth:
Full names of guardians for children under 18 for your wills:
Full names of backstop guardians:
My bank and branch:		Phone Number:
Postal address:		Email or Fax Number:
My accounting firm (if any):	Firm:	Accountant:
Phone Number:		Email or Fax Number:
Postal address:
My financial planners (if any):	Firm:	Accountant:
Phone Number:		Email or Fax Number:
Postal address:

Part 3 My wishes for the asset protection plan
My wishes after death	Partner 1	Partner 2
I wish the life support system to be turned off if there is no hope	☐ Yes ☐ No	☐ Yes ☐ No
I wish to be buried or cremated	☐ Buried ☐ Cremated	☐ Buried ☐ Cremated
My wishes as to a funeral service are
I wish to donate organs.	☐ Yes ☐ No	☐ Yes ☐ No
If yes I want these restrictions	I give any needed organs, tissues, or parts except my [insert details] the following organs, tissues, or parts only [insert details] to be used for: any purpose authorised by law. ☐ Yes ☐ No If no: [tick yes to include any one or more] transplantation. research. therapy. education. My organs, tissues, or parts should if possible be given to relatives of mine. ☐ Yes ☐ No If my relatives do not need organs, tissues, or parts, I desire that my organs, tissues, or parts be given to any other donee. ☐ Yes ☐ No	I give any needed organs, tissues, or parts except my [insert details] the following organs, tissues, or parts only [insert details] to be used for: any purpose authorised by law. ☐ Yes ☐ No If no: [tick yes to include any one or more] transplantation. research. therapy. education. My organs, tissues, or parts should if possible be given to relatives of mine. ☐ Yes ☐ No If my relatives do not need organs, tissues, or parts, I desire that my organs, tissues, or parts be given to any other donee. ☐ Yes ☐ No
Powers of Attorney, Wills & Trusts:
Trustee(s) of my will, Trustees of the Trust after my death, and property attorneys after my incapacity (all of whom should be the same for consistency). [All over 20]	My partner on their own: ☐ Yes ☐ No My partner with others: ☐ Yes ☐ No Children over 20: ☐ Yes ☐ No Others: ☐ Yes ☐ No Full names of others:	My partner on their own: ☐ Yes ☐ No My partner with others: ☐ Yes ☐ No Children over 20: ☐ Yes ☐ No Others: ☐ Yes ☐ No Full names of others:
My backstop Trustee(s) of my will, Trustees of the Trust after my death, and property attorneys after my incapacity. If you want more than one person together name them both as first: [All over 20] You should always have a backstop.	First: Children over 20: ☐ Yes ☐ No Others: Second:	First: Children over 20: ☐ Yes ☐ No Others: Second:
Welfare attorneys to look after my welfare if I am incapacitated: [One at a time] All must be 20 now.	First: My partner on their own: ☐ Yes ☐ No First/Second: Children over 20: ☐ Yes ☐ No In age order: ☐ Yes ☐ No Others: Second: Third: Fourth:	First: My partner on their own: ☐ Yes ☐ No First/Second: Children over 20: ☐ Yes ☐ No In age order: ☐ Yes ☐ No Others: Second: Third: Fourth:
Trusts: I want the Trust to be called:
Trustees of trusts
I want my own trustee company as trustee of the Trust	☐ Yes ☐ No	☐ Yes ☐ No
OR I want to be a trustee of the Trust	☐ Yes ☐ No	☐ Yes ☐ No
I want my partner to be a trustee of the Trust now	☐ Yes ☐ No	☐ Yes ☐ No
I want others (insert full names) to be trustees of the Trust now (not needed):	Full names:	Full names:
Who is to be the Protector after your death	The dispute resolver with power to hire and fire trustees after your death or incapacity
First	You ☐ Yes ☐ No	You ☐ Yes ☐ No
Second	Partner: ☐ Yes ☐ No	Partner: ☐ Yes ☐ No
I want to exclude the following as a beneficiary
Future Partners	☐ Yes ☐ No	☐ Yes ☐ No
Children's partners	☐ Yes ☐ No	☐ Yes ☐ No
When I die (in the case of a couple on the death of the first of us) I want my assets to go to:
Do you wish to make provision for the care of pets after your death?	☐ Yes ☐ No	☐ Yes ☐ No
Do you want to make any specific gifts in your will?	☐ Yes ☐ No If yes attach details:	☐ Yes ☐ No If yes attach details:
All to my Partner. If no: my partner is to receive the following interest, assets or percentage:	☐ Yes ☐ No	☐ Yes ☐ No
If no: my children are to receive the following interest, assets or percentages:
If no: others (include full names) are to receive the following interest, assets or percentage:
In the case of a couple on the death of both of us I want the children to receive this interest, assets or percentages:	Equally: ☐ Yes ☐ No	Equally: ☐ Yes ☐ No
In the case of a couple on the death of both of us I want the following (include full names) to receive this interest, assets or percentage:
If my children die before me I want their children to receive this interest, assets or percentage:	☐ Yes ☐ No	☐ Yes ☐ No
I want them to benefit at age:	☐ 20 ☐ 21 ☐ 25 ☐ 30 ☐ Other - Specify	☐ 20 ☐ 21 ☐ 25 ☐ 30 ☐ Other - Specify
I want them to benefit by: Compulsory trust	☐ Yes ☐ No	☐ Yes ☐ No
Optional trust	☐ Yes ☐ No	☐ Yes ☐ No
Inherit personally (not a recommended option)	☐ Yes ☐ No	☐ Yes ☐ No
Secondary beneficiaries: If all the above die I wish the following (include full names) to receive this interest, assets or percentage:	Equally: ☐ Yes ☐ No	Equally: ☐ Yes ☐ No

Part 4 My financial position
Income Details:	Partner 1	Partner 2
Yearly self employed income:	$	$
Yearly interest and dividend income:	$	$
Yearly employee income:	$	$
Yearly rental property income or losses	$	$
My income producing assets:
Term deposit or investment account details: Name of Bank/Issuer: Amount on deposit:
Term deposit or investment account details: Name of Bank/Issuer: Amount on deposit:
Life insurance policies: The insurance company's name: Policy number(s): Policy owner(s): Life(s) assured: Current surrender value:
Life insurance policies: The insurance company's name: Policy number(s): Policy owner(s): Life(s) assured: Current surrender value:
Superannuation Details: Company name: Owned by: Policy Number Current surrender value:
My assets which are likely to increase in value are:
Unit Trusts and Shares: Name of Company/Trust Reference number Number of Shares/Units: Current Value of Shares/Units: Date of valuation:
Properties: Address: Current Value $ Latest government valuation $ Certificate of title number:	My family home $ $	My family home $ $
There is a mortgage against the title: Is there a penalty for early repayment if the Trust purchases the property?: Name of lender: Address: Amount owed to lender $ The property the loan relates to is:	☐ Yes ☐ No ☐ Fixed interest ☐ Floating ☐ Flexi Credit ☐ Yes ☐ No	☐ Yes ☐ No ☐ Fixed interest ☐ Floating ☐ Flexi Credit ☐ Yes ☐ No
Properties: Address: Current Value $ Latest government valuation $ Certificate of title number:	My holiday home $ $	My holiday home $ $
There is a mortgage against the title: Is there a penalty for early repayment if the Trust purchases the property?: Name of lender: Address: Amount owed to lender $ The property the loan relates to is:	☐ Yes ☐ No ☐ Fixed interest ☐ Floating ☐ Flexi Credit ☐ Yes ☐ No	☐ Yes ☐ No ☐ Fixed interest ☐ Floating ☐ Flexi Credit ☐ Yes ☐ No
Rental properties: Address: Current Value $ Latest government valuation $ Certificate of title number: The properties annual loss is: Other income from investments can offset that loss:	My rental property $ $ $ ☐ Yes ☐ No	My rental property $ $ $ ☐ Yes ☐ No
There is a mortgage against the title: Is there a penalty for early repayment if the Trust purchases the property?: Name of lender: Address: Amount owed to lender $ The property the loan relates to is:	☐ Yes ☐ No ☐ Fixed interest ☐ Floating ☐ Flexi Credit ☐ Yes ☐ No	☐ Yes ☐ No ☐ Fixed interest ☐ Floating ☐ Flexi Credit ☐ Yes ☐ No
Total depreciation claimed for the rental properties are:	Buildings $ Chattels $	Buildings $ Chattels $
I am GST registered:	☐ Yes ☐ No GST reg no:	☐ Yes ☐ No GST reg no:
My other Assets: Attach details ( with market values)
I have shares in a private company	☐ Yes ☐ No	☐ Yes ☐ No
Name of the Company: I attach a copy of the last annual accounts, the number of shares in the company in total, the number of shares owned by us, the full names of all directors, and the full names of all shareholders.
There any losses carried forward for the company.	☐ Yes ☐ No	☐ Yes ☐ No
The company is a Loss attributing Qualifying Company	☐ Yes ☐ No	☐ Yes ☐ No
There are retained earnings	☐ Yes ☐ No	☐ Yes ☐ No
There any substantial risks of the company being sued	☐ Yes ☐ No	☐ Yes ☐ No
There risks are fully covered by insurance	☐ Yes ☐ No	☐ Yes ☐ No
The income paid to me by the Company is (before tax):	$	$
The commercial market rate salary I would pay someone else to do my job is:	$	$