Estate Planning Questionnaire

Your Information

Are you married?

Yes

U.S. Citizen

Yes

First Name

Middle Name

Last Name

Birth Date

Annual Income

SSN #

Primary Phone Number

Phone Type

Phone

Cell

Secondary Phone Number

Phone Type

Phone

Cell

Fax Number

Business Phone Number

Email Address

Your Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Referral Information - Who referred you to this office?

First Name

Last Name

Address

City

State

Zip Code

Referral is:

Attorney

Financial Planner

Previous Client of

Other

Previous Client Of / Other

Have you visited our website at www.rsteenlaw.com?

Yes

Do you have suggestions to improve our website?

Children List

Complete the children table below. Add more slots by pressing the (+) button.

Child Legal Name	Address	Home Phone	Work Phone	Birth Date

Grandchildren List

Complete the grandchildren table below. Add more slots by pressing the (+) button.

Child Legal Name	Address	Birth Date

Dispositive Intentions

Do you wish to provide primarily for your spouse and secondarily for your children?

Yes

Do you wish to treat all of your children equally?

Yes

If not, why?

After your spouse's death, at what age do you want distribution to your children? Typical distributions are 1/3 at age 25, 1/3 age 30, 1/3 age 35, or immediate.

Do you want to leave a specific amount of money or a percentage of your estate to your grandchildren?

Yes

Do you want to treat all of your grandchildren equally?

Yes

If not, why?

At what age do you want distribution to your grandchildren? (Typically, 1/3 at age 25, 1/3 age 30, 1/3 age 35, or immediate)

Do you want to leave a specific amount of money or other assets to any charity?

Yes

Charities

Name of Charity	Address	Dollar Amount

Do you want your Will to benefit anyone other than children, grandchildren, or a charity?

Yes

Other Beneficiaries

Name of Beneficiary	Address	Relationship	Dollar Amount

Executor

Who will server as your Executor?

Executor First Choice

Executor Second Choice

Executor Third Choice

Spouse Executor First Choice

Spouse Executor Second Choice

Spouse Executor Third Choice

Trustee

Who will serve as your Trustee?

Trustee First Choice

Trustee Second Choice

Spouse Trustee First Choice

Spouse Trustee Second Choice

Guardian

If you have a mionor or disabled child/children, whom do you want to act as Guardian?

Guardian First Choice

Guardian Second Choice

Health Care Agent

Do you want your Living Will to provide for withdrawal of artificial food and fluid?

Yes

Do you want to donate your eyes or organs?

Yes

Do you want your Health Care Agent to consult with any other person prior to acting?

Yes

If yes, with whom?

Name of Proposed Health Care Agent

Address / City / State / Zip

Name of Alternate Health Care Agent

Address / City / State / Zip

Spouse Health Care Agent

Do you want your Living Will to provide for withdrawal of artificial food and fluid?

Yes

Do you want to donate your eyes or organs?

Yes

Do you want your Health Care Agent to consult with any other person prior to acting?

Yes

If yes, with whom?

Name of Proposed Health Care Agent

Address / City / State / Zip

Name of Alternate Health Care Agent

Address / City / State / Zip

Primary Care Physician

Full Name of Physician

Address / City / State / Zip

Spouse Primary Care Physician

Full Name of Physician

Address / City / State / Zip

Financial Power of Attorney

Name of Proposed Financial Agent

Address / City / State / Zip

Spouse Financial Power of Attorney

Name of Proposed Financial Agent

Address / City / State / Zip

Miscellaneous

Do you have any legal issues I should be aware of?

Yes

Please explain.

Where are your important papers?

Do you have a Safe Deposit Box?

Yes

If yes, please indicate the location.

Have you (or spouse, if applicable) ever made gifts to any one person in excess of $15,000 in a single calendar year?

Yes

Have you ever filed a Federal Gift Tax Return?

Yes

Assets and Liabilities

Bank Accounts - We require copies of Statements

Amount	Ownership

Real Estate: Residence - We require copy of deed

Amount	Ownership

Real Estate: Other- We require copy of deed

Amount	Ownership

Savings Certificates - We require copies of statements

Amount	Ownership

Stocks: Non Mutual Funds Held by Broker - We require copies of statements

Amount	Ownership

Stocks: Non Mutual Funds NOT Held by Broker - We require copies of statements

Amount	Ownership

Bonds: Non Mutual Funds Held by Broker - We require copies of statements

Amount	Ownership

Bonds: Non Mutual Funds NOT Held by Broker - We require copies of statements

Amount	Ownership

Mutual Funds - We require copies of statements

Amount	Ownership

Note and Mortgage Receivables - We require Copies of Notes and Mortgages

Amount	Ownership

Business Interests - We require copies of stock certificates, partnership agreements, and/or other documentation.

Amount	Ownership

Inheritance, etc.

Amount	Ownership

Automobiles

Amount	Ownership

Jewelry and Collections listed on Insurance

Amount	Ownership

Non-IRA Tax Qualified Retirement Plans - We require statements

Amount	Ownership

IRA's - We require statements

Amount	Ownership

Life Insurance - We require copies of All Policies

Amount	Ownership

Annuities - We require copies of All Policies

Amount	Ownership

Other Assets- We require copies of relevant documents

Amount	Ownership

Bank Accounts - We require copies of Statements

Amount	Ownership

Real Estate: Residence - We require copy of deed

Amount	Ownership

Real Estate: Other- We require copy of deed

Amount	Ownership

Savings Certificates - We require copies of statements

Amount	Ownership

Stocks: Non Mutual Funds Held by Broker - We require copies of statements

Amount	Ownership

Stocks: Non Mutual Funds NOT Held by Broker - We require copies of statements

Amount	Ownership

Bonds: Non Mutual Funds Held by Broker - We require copies of statements

Amount	Ownership

Bonds: Non Mutual Funds NOT Held by Broker - We require copies of statements

Amount	Ownership

Mutual Funds - We require copies of statements

Amount	Ownership

Note and Mortgage Receivables - We require Copies of Notes and Mortgages

Amount	Ownership

Business Interests - We require copies of stock certificates, partnership agreements, and/or other documentation.

Amount	Ownership

Inheritance, etc.

Amount	Ownership

Automobiles

Amount	Ownership

Jewelry and Collections listed on Insurance

Amount	Ownership

Non-IRA Tax Qualified Retirement Plans - We require statements

Amount	Ownership

IRA's - We require statements

Amount	Ownership

Life Insurance - We require copies of All Policies

Amount	Ownership

Annuities - We require copies of All Policies

Amount	Ownership

Other Assets- We require copies of relevant documents

Amount	Ownership

Additional Assets (If Applicable)

Additional Assets Notes

Liabilities

Are you a contributor to a 529 Plan? If yes, we will require these statements.

Yes

Personal Residence
(Can be obtained from your tax bill)

Tax Block #

Lot #

Any real property other than personal residence.

Address / City / State / Zip	Tax Block #	Lot #

Any other Liabilities?

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Your Information

Previous Marriage

Spouse Information

Your Current Address

Referral Information - Who referred you to this office?

Children Information

Children List

Grandchildren List

Dispositive Intentions

Executor

Trustee

Guardian

Health Care Agent

Spouse Health Care Agent

Primary Care Physician

Spouse Primary Care Physician

Financial Power of Attorney

Spouse Financial Power of Attorney

Miscellaneous

Assets and Liabilities

Liabilities

Office Location