Estate Planning Questionnaire

This form is extremely important. Your accuracy and completeness in responding will help me represent you. Please bring this completed form to your appointment.

Are you married?

Yes

No

Do you have children?

Yes

No

Are your children from a previous marriage?

Yes

No

Do you have grandchildren?

Yes

No

Are you a U.S. Citizen?

Yes

No

Did someone refer you to our office?

Yes

No

Were you previously married?

Yes

No

Previous Marriage

Previous Spouse First Name

Previous Spouse Last Name

Previous Marriage Start Date

Previous Marriage End Date

Termination Reason

Death

Divorce

Annulment

Your Information

First Name

Middle Name

Last Name

Birth Date

Annual Income

Contact Information

Email(Required)

Phone Number

Cell Number

Fax Number

Business Number

Your Current Address

Street

City

State

Zip Code

Spouse Information

Does your spouse have children from previous marriage?

Yes

No

Is spouse a U.S. citizen?

Yes

No

Spouse First Name

Spouse Middle Name

Spouse Last Name

Spouse Birth Date

Spouse Annual Income

Spouse Phone Number

Spouse Cell Number

Spouse Fax Number

Spouse Business Phone Number

Spouse Email

Concerns

Are you concerned about potential litigation against you?

Yes

No

Do any of your family members have problems with:

Autoimmune Disease

Drug Addiction

Alcoholism

Marital Difficulty

Spendthrift

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

Yes

No

If you have legal issues, please explain.

Dispositive Intentions - Children

Leave any non-applicable answers blank

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

Yes

No

Do you wish to treat all of your children equally?

Yes

No

If you do not want to treat your children equally, why?

At what age do you want distribution to your children?

If married, distribution occurs after your spouses death. Typically, 1/3 at age 25, 1/3 age 30, 1/3 age 35 or Immediate.

Children List

Legal Name

Address

Home Phone

Work Phone

Birth Date

Dispositive Intentions - Grandchildren

Leave any non-applicable answers blank

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

Yes

No

Do you wish to treat all of your grandchildren equally?

Yes

No

If you do not want to treat your grandchildren equally, 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

Grandchildren List

Legal Name

Address

Birth Date

Dispositive Intentions - Beneficiaries

Leave any non-applicable answers blank

Do you want to leave a specific amount of money or other assets to any charity? If yes, list them below.

Yes

No

Charity

Name of Charity

Address (include zip)

Dollar Amount

Do you want your Will to benefit anyone other than children, grandchildren, or a charity? If yes, please list them below.

Yes

No

Other Beneficiaries

Name of Beneficiary

Address (include zip)

Relationship

Dollar Amount

Executor

Who will serve as your Executor?

Executor - First Choice

Executor - Second Choice

Executor - Third Choice

Trustee

Who will serve as your Trustee?

Trustee - First Choice

Trustee - Second Choice

Guardian

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

Guardian - First Choice

Guardian - Second Choice

Spouse Executor

Who will serve as your spouse's Executor?

Spouse Executor - First Choice

Spouse Executor - Second Choice

Spouse Executor - Third Choice

Spouse Trustee

Who will serve as your spouse's Trustee?

Spouse Trustee - First Choice

Spouse Trustee - Second Choice

Health Care Agent

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

Yes

No

Do you want to donate your eyes or organs?

Yes

No

Health Care Agent Name

Health Care Agent Address

Alternate Health Care Agent Name

Alternate Health Care Agent Address

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

Yes

No

If you want your Health Care Agent to consult with another person, with whom?

Spouse Health Care Agent

This section is for your spouse to complete

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

Yes

No

SPOUSE: Do you want to donate your eyes or organs?

Yes

No

SPOUSE: Health Care Agent Name

SPOUSE: Health Care Agent Address

SPOUSE: Alternate Health Care Agent Name

SPOUSE: Alternate Health Care Agent Address

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

Yes

No

SPOUSE: If you want your Health Care Agent to consult with another person, with whom?

Primary Care Physician

Primary Care Physician Name

Primary Care Physician Street Address

Primary Care Physician City

Primary Care Physician State

Primary Care Physician Zip

Spouse Primary Care Physician

This section is for your spouse to complete

SPOUSE: Primary Care Physician Name

SPOUSE: Primary Care Physician Street Address

SPOUSE: Primary Care Physician City

SPOUSE: Primary Care Physician State

SPOUSE: Primary Care Physician Zip

Financial Power of Attorney

Financial POA Name

Financial POA Address

Financial POA Alternate Name

Financial POA Alternate Address

Spouse Financial Power of Attorney

This section is for your spouse to complete

SPOUSE: Financial POA Name

SPOUSE: Financial POA Address

SPOUSE: Financial POA Alternate Name

SPOUSE: Financial POA Alternate Address

Miscellaneous

Where are your important papers?

Do you have a Safe Deposit Box?

Yes

No

If yes, where is your Safe Deposit Box located?

Have you (or spouse, if applicable) ever made gifts to any one person in excess of $17,000 in a single calendar year?

Yes

No

Have you ever filed a Federal Gift Tax Return?

Yes

No

Assets and Liabilities

We will need supporting document copies such as statements, deeds, notes and mortgages, partnership agreements, stock certificates, or policies.

Please list any assets or liabilities

Asset Type

Amount

Ownership

What is the total value of your assets listed above?

Are you a contributor to a 529 Plan? If yes, we will need the statements

Yes

No

Residence Information

Tax Block #

Obtained from your tax bill

Lot #

Obtained from your tax bill

Address of additional property other than personal residence

Additional Property Tax Block #

Obtained from your tax bill

Additional Property Lot #

Obtained from your tax bill

Address of additional real property other than personal residence

Additional Property Tax Block #

Obtained from your tax bill

Additional Property Lot #

Obtained from your tax bill

Any other Liabilities?

Referral Information

What is the name of the person who referred you?

What is the referrer's street address?

What is the referrer's city?

What is the referrer's state?

What is the referrer's zip?

The referrer is:

Attorney

Financial Planner

Previous Client

Other

Name of referring client:

If other, please explain:

Do you have anything else to tell us about your estate?

How can we improve our website?

Name

This field is for validation purposes and should be left unchanged.

Estate Planning