EVERGREEN QUESTIONNAIRE

The purpose of this questionnaire.

MERISTEM WEALTH MANAGEMENT LIMITED (MWML) will use the information you provide in this questionnaire:

1. To help you organize personal and financial information so that we can assess your estate plans and evaluate whether changes are desired or required.

2. The details provided in this questionnaire will be used to generate an initial proposal for your Evergreen plan. We crave your patience to thoroughly fill in the required information.

The information you provide must be as accurate as possible. If you are uncertain about exact information, please give your best assessment. We recognize that this questionnaire is an intrusive document and may require the divulgence of very private details and wish to reassure you that the information revealed or given in this questionnaire would be kept confidential unless you authorize or request its release to others.

Please be advised that the more complete the information is, the better it will equip you and MWML throughout the planning process to come up with the best possible plan.

State the names requested below exactly as you want them to appear in your account.

BIOGRAPHIC INFORMATION

First Name

Middle Name

Last name

Date of Birth

Spouse's name

Spouse Date of Birth

Home Address

Telephone No

State of Origin

Religion

Marital status

YOUR CHILDREN AND OTHER DEPENDENCE

How many Children do you have?

How many Dependencies do you have? Your dependency is anyone asides your children who depend on you as a source of livelihood.

PERSONAL AND FAMILY FINANCIAL ASSETS.

What is the Total Value of your Assets

ESTATE PLANNING

Expected retirement Age

Life expectancy post-retirement

Current Annual Salary

Estimated annual Expense in retirement

Do you have any concrete plan on how to transfer your Assets to your Beneficiaries?

What are your personal and specific estate planning objectives? E.g. financial dependence for children, charitable causes, management of asset in the event of incapacitation or demise etc.

Would you wish to appoint a Protector/Executor of your Estate Plan who will ensure that your objectives are fulfilled in your absence or incapacitation?