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Personal Estate Planner

Community Home Health & HospiceCare. Comfort. Love.

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We are pleased to provide you with this personal estate planner

This document will assist you in organizing and summarizing important records and financial information. It will provide your family and loved ones a list of important contacts, an inventory of your estate, how you wish to distribute your estate, and guidance for care of children.

This personal estate planner is NOT a will or legally binding. If you do not currently have a will we encourage you to contact an estate planning attorney for professional advice.

Charitable interests you may wish to consider…

We hope this planner helps you organize your affairs and plan for the future. You may wish to remember Community Home Health & Hospice in your will or with other planned gifts. Anyone can leave a lifetime gift—often referred to as estate planning—and you need not be wealthy to make these plans.

Planned gifts

Bequest Qualified retirement planLife insurance plan Charitable remainder trustCharitable gift annuity Charitable lead trust

Community Home Health & Hospice planning opportunities

Area of greatest needPatient care endowmentChildren’s bereavementHospice Care CenterVancouver expansionTelemonitoringStaff educationEmployee assistance Community Day Care

The Hospice Thrift Shop

Donate furniture, household décor, clothing and jewelry. Net proceeds from the shop help with patient charity care.

Volunteering

Numerous volunteer opportunities are available; simply contact Rudy Miniutti, volunteer coordinator, at 360.414.5433 or rminiutti@chhh.org.

For more information about including a gift to Community Home Health & Hospice as part of your estate plan, contact: Dev Dion at 360.414.5465 or ddion@chhh.org.

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Family Information

Date ____________________________

Full name _______________________________________________________________________________

Address _________________________________________________________________________________

City __________________________________State _____________ Zip code ________________________

Telephone ( ) ____________________________ Mobile ( ) ________________________________

Email __________________________________________________________________________________

Date of birth ________________________________________ Location of birth certificate _____________

Social Security number __________________ Employer __________________________________________

Veteran? yes no Service number ___________________VA number ______________________

Any disability? yes no Explain _______________________________________________________

Marital status _______________________ Name of spouse ________________________________________

Address _________________________________________________________________________________

Date of birth ____________________ Social Security number _____________________________________

Nearest relatives listed in the following order:

(1) Children

(2) Grandchildren

(3) Brothers and/or sisters

(4) Parents

Full name Relationship Age Address

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

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What do you have to will? An inventory of your estate

I. Personal property

A. Household goods (furnishings, furniture, books, musical instruments, auto, etc. List items for special consideration. Others may be grouped. If owned jointly, specify the joint owner.)

Item If jointly held, with whom Approximate value

Total approximate value $

B. Cash (Checking accounts)

Bank Address Acct. # If jointly held, with whom Amount

Total approximate value $

C. Cash (Savings accounts)

Bank Address Acct. # If jointly held, with whom Amount

Total approximate value $

D. Stocks & Bonds (government or other)Item If jointly held, with whom Approximate value

Total approximate value $

E. Money invested in mortgages and personal loans

Bank Address Acct. # If jointly held, with whom Amount

Total approximate value $

Total approximate value of all personal property (add items A, B, C, D and E). $ _______________

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How do you want your estate distributed?

You do not need to describe every item of your personal or real property in your will. Only list a specific item(s) or piece of property if you want it to go to a certain individual. And if you wish to name a specific sum of money to a person or organization, state the amount and the name.

Specific bequests: Person or organization (relationship) Address Item, property or

sum of money

After the specific bequests, if any, the simplest way to divide the remainder of your estate is by percentages. Name the person or organizations you wish to remember, then state what percentage of the total remaining amount of your estate each is to receive.

Specific bequests:Person or organization (relationship) Address Percentage (%)

Keep control - name your personal representative An executor/personal representative administers the estate after your death. You should name both an executor and an alternate executor. Name of executor/Personal representative Relationship Alternate executor/

Personal representative Relationship

Address: Address:

With bond Without bond With bond Without bond

Corporate executor

Name:

Address:

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Protect your children - name their guardian

If you have minor children, you should name a guardian for them in your will. This person has charge of both the children and the property you willed to them. You can narrow this service by having a guardian care only for the children, then name a separate executor or trustee for their estate. He or she holds the property and expends it as directed by your will.

Name of guardian Relationship Alternate guardian Relationship

Address: Address:

Personal representative name: Relationship:

Address:

My professional advisorsMy minister:

Address: City: State: Zip:

My attorney:

Address: City: State: Zip:

My insurance agent:

Address: City: State: Zip:

My accountant:

Address: City: State: Zip:

My banker or trust officer:

Address: City: State: Zip:

My broker:

Address: City: State: Zip:

My tax records are located:

Address: City: State: Zip:

My safe deposit box is located:

Address: City: State: Zip:

My will or living trust is located:

Address: City: State: Zip:

My living will is located:

Address: City: State: Zip:

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Inventory

II. Real property (real estate and buildings)

Type of property Address If jointly held,with whom Approximate value

Total approximate value of real property $

III. InsuranceIf the beneficiary of your life insurance policy should precede you in death leaving no other beneficiary, the insurance would be payable to your estate and should be covered by your will.

Company Type of policy Beneficiary Amount

Total value of insurance $

IV. Retirement plans

Type of plan Plan administrator and address Beneficiary Approximate value

Total approximate value of retirement plans $

Total approximate value of all assets (add items I, II, III, IV) A. $ ________________

V. Approximate debts and mortgages against your estate

Debt or mortgage to whom? Address Amount

Total indebtedness B. $

NET ESTATE VALUE (A-B) $ ___________________

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An inventory of your estate

Costs vs. value of investments(Items on pages 2 and 3 that represent potential capital gain should be detailed below.)

Asset description Exact title of ownership Current value Date and how

acquired Net annual yield

Your signature Date

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1. Distribution clarification (relates to page 5)

One method of distributing the assets of your estate is by outright distribution. By simple will, you leave what remains of your estate, after debts and costs, outright to those you desire to receive such an estate. In some instances, your wishes may be more fully carried out with avoidance of unnecessary costs by incorporating a testamentary or living trust in your will.

Check one: q A. Simple will (outright distribution) q B. Will with testamentary or living trust

2. Testamentary or living trust to be used

A. Primary purpose for trust:• To give spouse or other named person financial assistance and security without management

responsibility• To assist children or grandchildren until they are capable of handling their own affairs

• Other:

B. How do you want the principal ultimately distributed?

To whom? _______________________________________________________________

________________________________________________________________________

________________________________________________________________________

At what age or time? _______________________________________________________

________________________________________________________________________

________________________________________________________________________

What percentage? __________________________________________________________

________________________________________________________________________

C. Other specifics: ____________________________________________________________________

________________________________________________________________________

The next steps:

Once you complete this personal estate planner you should keep it in a safe location and advise family member or personal representative where they can find the document when the need arises. If you have a will you should consider keeping the documents together. If you do not have a will we recommend you contact an attorney to help you with this important document.

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Words about wills: a short glossaryBeneficiary A person who receives benefits under a will or from a trust.

Bequest A gift of personal property made in a will.

Codicil A supplement which adds to, deletes from or changes the provisions of a will.

Contingent beneficiary A beneficiary who receives a benefit only if a future event occurs.

Estate tax The tax on the estate of a deceased person.

Executor/executrix or personal representative

The person or corporation appointed to probate or settle the estate of a testate person (a person who dies WITH a will).

Guardian of the person The person who has legal care and control over a minor or an incompetent adult.

Guardian of the property

The person who has legal care and control over the property of a minor or an incompetent adult.

Inheritance tax The tax on recipients of a deceased person’s property.

Intestate To be without a valid will.

Irrevocable Cannot be revised or changed.

Issue Offspring or descendants. Your children, grandchildren, great-grandchildren and so forth.

Joint tenancy with A way of holding title to property by two or more persons so that when one person dies, her or his share right of survivorship automatically goes to the surviving joint tenants, and not under the deceased person’s will or under the laws of intestacy.

Legacy A gift of personal property made in a will; the same thing as a “bequest.”

Living trust A trust established by an individual while still living.

Living will A written statement instructing others of your wishes concerning life-prolonging medical care when your death appears inevitable.

Pour-over will A will that transfers all, or a portion of an estate into a pre-existing living trust.

Power of attorney A written instruction by which a person authorizes another person to act for her or him in a limited or general capacity.

Probate The process of settling an estate of a deceased person and transferring her or his property to heirs or beneficiaries done under supervision of the probate court.

Real property Land and fixed improvements, and growing things on such land.

Residue The remainder of an estate after specific gifts are made.

Revocable Subject to being revoked, canceled, changed or modified.

Settlor A person who establishes a trust.

Tenancy in common A way of holding title to property by two or more persons so that when one person dies, her or his share is disposed of by will or as part of her or his intestacy property.

Title Ownership

TrustAn arrangement whereby one person (the settlor) transfers real and/or personal property to another person (the trustee) to hold for the benefit of a third person (the beneficiary) or the settlor.

Trustee The person or institution who holds trust property, manages it and distributes it to the beneficiaries.

Will

A document which, if executed in accordance with legal requirements, will distribute property held in your name alone and your interest in a tenancy in common. Usually, it will not govern lift insurance, property held as a joint tenant with right of survivorship or as a tenant by entirety, or property held in a living trust.

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Dr. and Mrs. Larry McRae cherish the memories of their loved ones who received our care. Carol remembers when her mother settled into the Hospice Care Center in Longview and asked, “Is this heaven?” It was private, quiet and comfortable and the family received all the support that they needed.

In Carol’s words, “while it’s important to have a place for patients to get well, there also has to be a place for people to learn how to die—where you can sit down and talk about what to do.”

The McRaes want future generations to have access to skilled, compassionate care. For that reason, it was easy for them to include Community Home Health & Hospice in their will. To inspire others to do the same, they became founding members of the Community Legacy Society.

Many planned gifts offer tax benefits. Some may even pay you an income for life. If you would like to name us in your will or notify us of your support, contact Dev at 360.414.5465 or ddion@chhh.org.

Dr. Laird and Mrs. Carol McRae

“Take care of your family and then look into the future. It is important to establish an estate giving plan. Have a vision to gracefully handle the remaining estate and assure home health and hospice care is available for future generations.”

~Dr. Laird McRae

CarE for Future GEnErations

Community Home Health & HospiceCare. Comfort. Love.

Community Home Health & Hospice is a nonprofit 501c(3) tax-exempt organization serving the following four counties: Cowlitz, Clark and Wahkiakum in Washington, and Columbia in Oregon. This booklet is not intended as legal or tax advice, but as general information about planned giving. For legal or tax advice, please consult a professional advisor. Our legal name is Community Home Health/Hospice. Tax ID 91-1399370.

MissionCommunity Home Health & Hospice supports the healthcare and independent living goals of each patient and their loved ones by delivering the highest quality,

compassionate and dignified care to individuals in their chosen place of residence.

1035 11th avenue • Po Box 2067 Longview, Wa 98632

14508 nE 20th avenue • ste. 201Vancouver, Wa 98686

www.chhh.org��0�PEP