Estate Planning Questionnaire - Burton Law LLC

Single

CLIENT INFORMATION

[Strictly Confidential]

Legal Name

First NameMiddle NameLast Name

Other Names used

Address

Street Address

City

State / ProvincePostal / Zip Code

County

Email

example@example.com

Telephone (home)

Area CodePhone Number

Telephone (work)

Area CodePhone Number

Telephone (cell)

Area CodePhone Number

Smartphone?

YesNo

Which one?

AndroidiPhone?

Date of Birth

MonthDayYear

Soc. Sec No. (Last 4 Digits)

Business/Employer

Marital Status

Never marriedDivorcedWidowedMarried

Name of Spouse

US citizen?

YesNo

What nationality?

CHILDREN

None

Please list First Name, Middle Initial, Last Name for all children listed below.

	NAME	AGE or DOB
1.
2.
3.
4.

Number of grandchildren

Range of Ages

Any deceased children?

YesNo

Name

Survived by issue?

YesNo

Name(s)

	YES	NO
Do any of your beneficiaries have a learning disability, special educational, medical or physical needs?
Do you have any relatives (other than children) who depend on you for all or part of their support?
Do you think any of your beneficiaries have special problems with spouses, drugs, alcohol or handling money?
Do you wish to disinherit any of your children, grandchildren or any other close relative?
If a named beneficiary dies before you, do you want the assets to go to that beneficiary’s issue?
Do you want assets passing to your beneficiaries to be held in trust until a specific age or ages?
Do you expect to inherit substantial assets ($100,000 +)?
Do you have an existing Will?
Have you ever executed a trust (either revocable or irrevocable)?
Have you ever filed a Federal Gift Tax Return?
Do you have an existing General Power of Attorney?
Do you currently hold any assets in Joint Tenancy with another person?
Do you want to pay your Trustee if they are a family member?

PERSONAL REPRESENTATIVE OR TRUSTEE

The name of the person(s) that you want to be the decision maker concerning your estate upon your death:

Primary Personal Representative (PR)

First NameMiddle NameLast Name

Successor Personal Representative

First NameMiddle NameLast Name

GUARDIAN FOR MINOR CHILDREN

The name of the person(s) that you want to raise a child that is under 18 (if applicable):

Primary Guardian

First NameMiddle NameLast Name

Address

Street Address

City

State / ProvincePostal / Zip Code

County

Successor Guardian

First NameMiddle NameLast Name

Address

Street Address

City

State / ProvincePostal / Zip Code

County

HEALTH CARE AGENT

The name of the person(s) that you want to make any major medical decisions on your behalf:

Primary Agent

First NameMiddle NameLast Name

Address

Street Address

City

State / ProvincePostal / Zip Code

County

Phone Number

Area CodePhone Number

Successor Agent

First NameMiddle NameLast Name

Address

Street Address

City

State / ProvincePostal / Zip Code

County

Phone Number

Area CodePhone Number

AGENT—POWER OF ATTORNEY FOR FINANCES & PROPERTY

The name of the person(s) that you want to make financial decisions on your behalf if you are incapacitated:

Primary Agent

First NameMiddle NameLast Name

Address

Street Address

City

State / ProvincePostal / Zip Code

County

Phone Number

Area CodePhone Number

Successor Agent (optional)

First NameMiddle NameLast Name

Address

Street Address

City

State / ProvincePostal / Zip Code

County

Phone Number

Area CodePhone Number

In general, state how you want your estate distributed among your beneficiaries?

State any specific concerns (not already mentioned) that you have regarding the distribution of your estate:

How did you find my office?

If you used my website, did you have any issues navigating the website or any other comments/feedback on the website?

Name of Financial Advisor (if any)

First NameMiddle NameLast Name

Firm Name and Address

Phone/Fax/Email

Name of Bank or Financial Institution

Address

Street Address

City

State / ProvincePostal / Zip Code

County

BURIAL WISHES

At my death, I wish to be

CrematedBuried

I would like my ashes disposed as follows:

I would like my remains interred as follows:

I have already made arrangements at:

ESTIMATED* VALUE OF ESTATE

TYPE OF ASSET: ESTIMATED VALUE

TOTAL REAL ESTATE: (fair market value, less loans)

$

Address of each piece of real estate:

Property #1:

Address

Street Address

Street Address Line 2

State / ProvinceCounty

Tax Parcel ID No. (if known):

How is the Deed Titled?

Estimated Fair Market Value:

Mortgages on the Property (Please list the total of all mortgages on property):

Any joint owners? If yes, please list:

Property #2:

Address

Street Address

Street Address Line 2

State / ProvinceCounty

Estimated Fair Market Value:

Mortgages on the Property (Please list the total of all mortgages on property):

How is the Deed Titled?

Any joint owners? If yes, please list:

Property #3:

Address

Street Address

Street Address Line 2

State / ProvinceCounty

Estimated Fair Market Value:

Mortgages on the Property (Please list the total of all mortgages on property):

How is the Deed Titled?

Any joint owners? If yes, please list:

PLEASE ATTACH COPIES OF ANY DEEDS YOU HAVE READILY AVAILABLE FOR REAL ESTATE WHEN YOU RETURN THIS FORM. THANK YOU!

	$
SECURITIES: (stocks, bonds, mutual funds)
CASH TYPE ASSETS: (cash, annuities, notes due you)
BUSINESS INTERESTS: (sole proprietorship, partnerships, closely held corporation, etc.)
RETIREMENT PLANS: (IRA, 401k, etc.**)
VEHICLES: (autos, R.V., boat)
PERSONAL PROPERTY: (jewelry, furniture, antiques)

TOTAL:

* Use best guess; this can be a “ballpark” estimate.

** Do not show benefits which will terminate at death (e.g., pension, social security, etc.).
Value of Life Insurance policies will be listed separately on the next page.

LIFE INSURANCE
(do not include accidental death policies)

• "Cash Value" use best estimate (term policies normally have no cash value)
• "Face Value" is the amount payable at death

	COMPANY	CASH VALUE ($)	FACE VALUE ($)	BENEFICIARY
1.
2.
3.
4.
5.
6.

Instructions Regarding Real Estate Deeds and Other Paperwork:

When returning this document, please attach copies of any deeds for real property that you have readily available. If you do not have the deeds available when you return the questionnaire you may also bring this paperwork with you to the initial consultation. If you do not have the deeds available, please make a note and I can search for them online if necessary for a small fee. Please feel free to attach bank statements, investment account statements, titles, or paperwork concerning other valuable assets that you believe would be useful to me when returning this document. Thank you for completing this questionnaire and for working with me to make your initial consultation as efficient and effective as possible!

Scheduling Your Estate Planning Design Meeting:

When you have completed this questionnaire and returned it to my office, please contact the office by email at attorney@theburtonlawoffice.com to schedule an appointment for your initial consultation where we will review your questionnaire and design a custom estate plan designed to fit your needs. Clients who return the questionnaire first will receive first priority in scheduling available appointments. Thank you for your understanding and cooperation!

Instructions for Returning Completed Estate Planning Questionnaire:

Email or online electronic submission is the preferred method for receiving the completed questionnaire. If you are filling this form out via JotForm, please save a copy to your own computer for future reference, then when you are finished click "Submit" at the bottom of the form. You can also click "Print Form" and bring a printed copy of your completed questionnaire with you to your Estate Planning Design Meeting for reference during our meeting. Finally, if you have additional attachments to include, please send them separately by email to attorney@theburtonlawoffice.com.

If you complete this form and wish to send it to our office via email, please send in PDF format to:

attorney@theburtonlawoffice.com