Confidential
Estate
Planning questionnaire
(PLEASE BE SURE TO CHECK ALL appropriate boxes. If “none”, please state “NONE”. If “not applicable”, please state “NOT APPLICABLE”. PLEASE FILL OUT COMPLETELY.)
PERSONAL
DATA As the person signing the Will and for your spouse’s Will, if
applicable. (Spouse can include a wife,
husband, co-habitation partner) Please
provide the following:
First
M. I. Last
First M.
I. Last
3. Address:
Street Address City State Zip
4. Telephone:
Home Work
5. Your
Birthdate: 6.
Social Security #
7. Spouse’s
B.D.: 8.
Spouse’s SS #
9. Please
indicate if you (or your spouse) are or have been known by any other name:
First
M.
I. Last
10. Please mark the box adjacent to your
current situation:
¨ Married ¨ Unmarried
¨ Divorced ¨ Widowed
¨ Other:
11. If you are married, please provide the
following:
Date of Marriage:
Place of Marriage:
City State
CHILDREN (Please name all children born or adopted by
you and note if they are the children of a prior marriage. Please list stepchildren in the spaces
provided. Please use the other side of
this sheet if you need more room.)
1. Name:
Birthdate:
Residing at:
City State
2. Name:
Birthdate:
Residing at:
City State
3. Name:
Birthdate:
Residing at:
City State
4. Name:
Birthdate:
Residing at:
City State
Stepchildren: (If you need more room, please use the other side of this
sheet.)
1. Name:
Birthdate:
Residing at:
City State
2. Name:
Birthdate:
Residing at:
City State
3. Name:
Birthdate:
Residing at:
City State
Deceased Children: (Do you have any deceased children, with surviving
children?; If so, please list)
Are there any persons (other than minor children) who are partially or wholly dependent upon either you or your spouse (if applicable) for support now or possibly in the future? If yes please name:
ASSETS Please
indicate the total present market value (as best you can determine) of ALL
of your “PROPERTY”, (held in your name alone and/or jointly with your
spouse). A “worksheet” will be provided
upon request to assist you in determining your net estate value.
ALL of your
“PROPERTY” shall include, but not be limited to, the following:
1. Real Estate (Exclusive of
present mortgage balances, if any);
2. Personal/Household/Office/Business items such as (a) furniture, (b) collectibles, (c) cars, (d) boats, (e) planes, (f) recreational equipment, (g) professional equipment, (h) furs, (i) jewelry, etc.;
3. Personal/Business Bank Accounts, etc. (a) savings, (b) checking, (c) certificates, etc.;
4. Insurance (a) on your life (death benefit amount), (b) Retirement Plans and/or Union Death Benefits, etc.;
5. Stocks and Bonds, etc. (a) mutual
funds, etc.
6. Business
Interests (a) the value of any interest you may have in a business venture,
(b) royalties, (c) annuities, (d) profit-sharing, etc.;
7. Debts
Owed to You – Personal/Business (less debts owed by you);
OF ALL OF YOUR
ASSETS: $
TOTAL LIABILITIES: $
NET WORTH (Approximate) $
Have you
established a trust for the benefit of anyone else or has anyone else
established a trust for your benefit or the benefit of your spouse? ¨ Yes ¨ No
PLANNING OBJECTIVES AND PRIORITIES. Please
describe any significant planning objectives or priorities you may have.
NOTE: A person will be disqualified from
acting as PERSONAL REPRESENTATIVE, GUARDIAN and TRUSTEE due to the fact the
he/she/they is/are:
1. less than eighteen (18) years of age;
or
2. an incompetent (judicially declared);
or
3. a non-United States citizen who does
not reside in the
4. a convicted felon.
PERSONAL REPRESENTATIVE (ESTATE EXECUTOR (MALE) – EXECUTRIX (FEMALE))
The person charged
with administering your estate, paying taxes and/or other debts, and
preserving, managing and distributing estate assets and property is called a
Personal Representative or an Executor/Executrix.
The person
nominated for this roll should be one in whom you have complete trust and
confidence. (Your spouse may be named as the primary Personal Representative, if you
desire.)
Please provide the following information about the person(s) you wish to name to serve in this capacity. Please name additional alternates on the other side of this page.
1. Primary Choice of PERSONAL REPRESENTATIVE(s):
First Name M.I. Last Name Residence
Relationship: ¨ Male ¨ Female
Joint
PERSONAL REPRESENTATIVE (If you desire):
First Name M.I. Last Name Residence
Relationship: ¨ Male ¨ Female
2. Alternate PERSONAL REPRESENTATIVE(s):
First Name M.I. Last Name Residence
Relationship: ¨ Male ¨ Female
Joint
Alternate PERSONAL REPRESENTATIVE (If you
desire):
First Name M.I. Last Name Residence
Relationship: ¨ Male ¨ Female
GUARDIAN(S) OF MINOR CHILDREN
The surviving
parent of a child under the age of eighteen (18) years old is ordinarily
entitled to be the GUARDIAN of that child.
If you are a single
parent or legal guardian or in the case of the simultaneous death of you and
your spouse, you should appoint a GUARDIAN for your child or children under the
age of eighteen (18) years old. It is
advisable, prior to the completion of this Questionnaire, to make sure that
your proposed GUARDIAN(S) is (are) willing to serve as GUARDIAN(S) prior to
your appointment of him/her/them.
Please provide the following information about the person(s) you select to be GUARDIAN(S).
In the event my
spouse predeceases me, I name as GUARDIAN(S):
1. Primary Choice of GUARDIAN(S):
First Name M.I. Last Name Residence
Relationship: ¨ Male ¨ Female
Joint
GUARDIAN (If you desire):
First Name M.I. Last Name Residence
Relationship: ¨ Male ¨ Female
2. Alternate GUARDIAN(S):
First Name M.I. Last Name Residence
Relationship: ¨ Male ¨ Female
Joint Alternate GUARDIAN (If you desire):
First Name M.I. Last Name Residence
Relationship: ¨ Male ¨ Female
TRUSTEE(S):
If any of your
children are less than eighteen years of age at the time of your death and your
spouse has predeceased you, that child’s or those children’s share of your
estate, should be placed in a trust and held until the child is eighteen years
old or an age designated by you for distribution to the child.
You should appoint
a TRUSTEE(S) of your child’s or children’s estate. It is advisable, prior to the completion of
this Questionnaire, to make sure that your proposed TRUSTEE(S) is (are) willing
to serve as TRUSTEE(S) prior to your appointment of him/her/them.
The person
nominated for this roll should be one in whom you have complete trust and
confidence.
Please provide the following information about the person(s) you select to be TRUSTEE(S).
In the event my
spouse predeceases me, I name as TRUSTEE(S):
1. Primary Choice of TRUSTEE(S):
First Name M.I. Last Name Residence
Relationship: ¨ Male ¨ Female
Joint
TRUSTEE(S) (If you desire):
First Name M.I. Last Name Residence
Relationship: ¨ Male ¨ Female
2. Alternate TRUSTEE(S):
First Name M.I. Last Name Residence
Relationship: ¨ Male ¨ Female
Joint
Alternate TRUSTEE(S) (If you desire):
First Name M.I. Last Name Residence
Relationship: ¨ Male ¨ Female
DISTRIBUTION OF “TRUST” ESTATE (If applicable)
(Attorney will discuss the distribution of
Trust Estate with you further at the initial conference.)
Age of youngest
child before first distribution:
Age for periodic
distribution(s), if applicable:
First
Portion Second Portion
Third Portion Fourth Portion
SPECIFIC BEQUESTS
A “Specific Bequests” is a
gift of a certain portion or amount of your estate to a specific
individual(s). You can give personal
property in a specific bequest, but it is advised against as personal property
is too likely be sold or lost before your death. We suggest that you only list real property,
intangible personal property (stocks, bonds, C.D.s, etc.) and cash lump sums in
your specific bequests.
Please list the individual(s) you wish to make a specific bequest and
the property being bequested to them below, if applicable. Please use the other side of this page if you
need more room.
1. Name:
Residing at:
City State
Bequest:
2. Name:
Residing at:
City State
Bequest:
Here is where you
need to indicate how you want your estate distributed. Please list the beneficiaries and the order
of distributions you wish to outline in your Will in the space provided
below. If you are married, please name
the alternate beneficiaries of your estate if your spouse were to predecease
you. (Please use the other side of this
sheet if you need more room.)
1. Name:
Residing at:
City State
Bequest:
2. Name:
Residing at:
City State
Bequest:
3. Name:
Residing at:
City State
Bequest:
4. Name:
Residing at:
City State
Bequest:
In the event that your spouse has predeceased you and all named beneficiaries of your Will have predeceased you, you will need to distribute all of the rest, residue and remainder of your estate not otherwise effectively bequeathed under the provisions of your Will to alternate beneficiaries or charities or your estate will be divided as provided by intestate laws. If you desire, please list your contingent beneficiaries below.
(INTESTATE LAWS: Statutes
which provide and prescribe the devolution of estates of persons who die
without disposing of their estates by law, will or testament. Black’s Law
Dictionary)
1. Name:
Residing at:
City State
Bequest:
2. Name:
Residing at:
City State
Bequest:
3. Name:
Residing at:
City State
Bequest:
FUNERAL/BURIAL ARRANGEMENTS (Note: We do not
recommend that this provision be included in the Will because the contents of
the Will are not always known to the person in charge until after the deceased
has already been buried. It is suggested
that if the client has specific wishes, that they be made known to the persons
who would be in charge at the time of his death.)
OTHER SPECIFIC PROVISIONS or information to
be included in Will, such as operation or provision for family business, etc.
COMMUNITY PROPERTY AGREEMENT (CPA) (If Married)
(The Community
Property Agreement is a document in which each spouse agrees that all community
property vests in the surviving spouse upon the death of the first spouse. It is an excellent probate avoidance
mechanism.)
Have you ever
signed a Community Property Agreement? ¨ Yes ¨ No
If yes, date signed and if recorded,
what county?:
If no, are you interested in signing
a CPA? ¨ Yes ¨ No
Have you ever
signed a Separate Property Agreement? ¨ Yes ¨ No
If yes, date signed and if recorded,
what county?:
Have you ever
signed any other agreements between spouses regarding property? ¨ Yes ¨ No
Have any of the
agreements you have signed been filed in any county? ¨Yes ¨ No
If yes, which county(ies)?
Please furnish a
copy of any agreements.
(The Durable Power of Attorney is a document that would become effective upon the proven incompetency of an individual to handle their own affairs. The value of this document is that it would avoid the necessity of a guardianship in the event of incompetency.)
Have you ever
signed a Durable Power of Attorney? ¨ Yes ¨ No
If yes, date signed and if recorded,
what county?:
If no, are you interested in signing
a DPA? ¨ Yes ¨ No
The individual you name in the DPA to handle your affairs in the event of incompetency is known as the attorney-in-fact. Please provide the name of the person(s) you wish to nominate as your attorney-in-fact and provide the city and state of their residence.
Attorney-in-Fact(s)
Name City State
Alternate
Attorney-in-Fact(s)
Name City State
HEALTH CARE DIRECTIVE (Living Will) (HCD)
(The purpose of the
Health Care Directive (Directive to Physicians) is to make known the desire of
the person signing the document of his wish not to have his life
"artificially prolonged" in the case of any injury, disease, or
terminal condition.)
Have you ever
signed a Health Care Directive? ¨ Yes ¨ No
Are you interested
in signing a Heath Care Directive? ¨ Yes ¨ No
COMMENTS
AND/OR QUESTIONS (Please list any comments and/or questions
you have with respect to this Questionnaire and your estate plan. We can discuss any comments and/or questions
when we meet.)