Estate Planning Questionnaire Burton Law LLC

Married Couple

CLIENT INFORMATION

[Strictly Confidential]

Husband’s Legal Name

First NameMiddle NameLast Name

Other Names used by Husband

Address

Street Address

City

State / ProvincePostal / Zip Code

County

Email

example@example.com

Telephone (home)

Area CodePhone Number

Telephone (cell)

Area CodePhone Number

Android or iPhone?

AndroidiPhone?

Date of Birth

MonthDayYear

Soc. Sec No. (Last 4 Digits)

US citizen?

YesNo

What nationality?

Business/Employer

Wife's Legal Name

First NameMiddle NameLast Name

Other Names used by Wife

Date of Birth

MonthDayYear

Soc. Sec No. (Last 4 Digits)

Telephone (home)

Area CodePhone Number

Telephone (cell)

Area CodePhone Number

Android or iPhone?

AndroidiPhone?

Business/Employer

Email

example@example.com

US citizen?

YesNo

What nationality?

Prior Marriages?

Husband:

YesNo

Name of prior spouse

How Terminated?

DeathDivorce

Date

Wife:

YesNo

Name of prior spouse

How Terminated?

DeathDivorce

Date

CHILDREN OF THIS MARRIAGE

None

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

	NAME	AGE or DOB
1.
2.
3.
4.
5.
6.
7.

Number of grandchildren

Range of Ages

CHILDREN FROM PRIOR MARRIAGE:

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

	NAME	WIFE	HUSBAND	AGE
1.
2.
3.
4.
5.

Treat all children as if they were the children of this marriage?

NoYes

Any deceased children?

YesNo

Name

Survived by issue?

YesNo

Any adopted children?

YesNo

Name

	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?
Do you have an existing Marital Property Agreement?
Do either of you expect to inherit substantial assets ($100,000 +)?
Do you have an existing Will?
Do you have any existing trusts?
Have you ever filed a Federal Gift Tax Return?
Should the surviving spouse have the power to control the distribution of the entire estate after the first death?
Do you want any assets to pass to your children before the second spouse's death?
If a beneficiary dies prior to the second spouse’s death, 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 want to pay your Trustee if they are a Family Member?
Do you treat all of your property as Marital Property with your spouse?

PERSONAL REPRESENTATIVE AND/OR TRUSTEE

The name of the person(s) other than the surviving spouse that you want to be the decision maker concerning your estate upon your death
(Personal Representative for Will Plan or Trustee for Trust Plan):

(1)

First NameMiddle NameLast Name

(2)

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 both
spouses die (Guardian) (if applicable):

(1)

First NameMiddle NameLast Name

(2)

First NameMiddle NameLast Name

HEALTH CARE AGENT

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

HUSBAND

Primary Health Care Agent

First NameMiddle NameLast Name

Address

Street Address

City

State / ProvincePostal / Zip Code

County

Phone Number

Area CodePhone Number

Successor Health Care Agent

First NameMiddle NameLast Name

Address

Street Address

City

State / ProvincePostal / Zip Code

County

Phone Number

Area CodePhone Number

WIFE

Primary Health Care Agent

First NameMiddle NameLast Name

Address

Street Address

City

State / ProvincePostal / Zip Code

County

Phone Number

Area CodePhone Number

Successor Health Care 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 (Agent for Financial Power of Attorney):

HUSBAND

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

WIFE

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

In general, state how you want your estate distributed among your beneficiaries after the death of both of you?

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

BURIAL WISHES

HUSBAND:

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:

WIFE:

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:

	HUSBAND'S SEP. PROP ($)	WIFE'S SEP. PROP ($)	COMMUNITY PROPERTY ($)
REAL ESTATE: (fair market value, less loans)
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: HUSBAND'S SEP. PROP ($)

WIFE'S SEP. PROP ($)

COMMUNITY PROPERTY ($)

* 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.

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:

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

LIFE INSURANCE
(do not include accidental death policies)

• "Insured" will be "H" husband; "W" wife; or "S" survivor
• "Owner" will be "C" community property; "H" husband or "W" wife
• "Cash Value" use best estimate (term policies normally have no cash value)
• "Face Value" is the amount payable at death
• "Beneficiary" will be "H" husband; "W" wife; "C" child, "O" other

	INSURED (H/W/S)	OWNER (H/W/C)	CASH VALUE ($ estimate)	BENEFICIARY (H/W/C/O)	Life Ins. Co. Name
2.
3.
4.
5.
6.

WAIVER OF POTENTIAL CONFLICT OF INTEREST

We have each read the foregoing material and understand that there are potential conflicts of interest between myself and my spouse in the matters about which we are consulting you. If either of us desire to have separate counsel or desire you not to be involved at all, that spouse shall notify you. We each hereby consent to having you represent both of us in the drafting of our estate planning documents and we each hereby waive any potential or actual conflicts of interest. We understand that since you will be representing both of us on the same matter, as between ourselves and you, there are no confidential communications.

Dated

Date

Husband’s Signature

Wife’s Signature

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