ESTATE PLANNING QUESTIONNAIRE

GULOTTA & GULOTTA, PLLC

2459 Ocean Avenue, Suite A Ronkonkoma, New York 11779 p: 631.285.7000 f: 631.285.7006 e: info@gulottagulotta.com https://gulottagulotta.com
ESTATE PLANNING QUESTIONNAIRE
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
Do you identify as :

MaleFemaleOther
What is your marital status?

married once and spouse is alivemarried and spouse is alive, but married beforewidower / widow - singledivorced - singlesingle - never marriedsame sex marriage / domestic partnership / civil union
Spouse

First NameMiddle NameLast Name
CHILDREN
How Many Children Do You Have (include step and adopted children)
Child #1

First NameMiddle NameLast Name
Age
0-100 yr.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child #1 Phone Number

Area CodePhone Number
Child #2

First NameMiddle NameLast Name
Age
0-100 yr.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Child #3

First NameMiddle NameLast Name
Age
0-100 yr.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Additional Child(ren) Information:
ASSETS
Estimated combined assets of you & spouse upon death (include life insurance proceeds or inheritance from others). Give a higher estimate rather than lower

Under $500,000$500,000-$1,000,000Over $1,000,000Over $3,000,000Over $5,000,000Over $10,000,000
Do You Own Any Real Estate? (If owned 'jointly,' then it will pass to the survivor)

YesNo
Property #1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How would you like Property #1 to be distributed?

All to spouse if he/she survives meAll as part of residuary estateJust the home to spouse & all other real estate with residuarySpouse to have a life estate (may live in house for rest of life)To be sold (costs of the sale will be expenses of estate)To 1 or more beneficiaries (specify below):
Specify Primary Beneficiaries and Alternate Beneficiaries
Property #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How would you like Property #2 to be distributed?

All to spouse if he/she survives meAll as part of residuary estateJust the home to spouse & all other real estate with residuarySpouse to have a life estate (may live in house for rest of life)To be sold (costs of the sale will be expenses of estate)To 1 or more beneficiaries (specify below):
Specify Primary Beneficiaries and Alternate Beneficiaries
Additional Property Information:
Specify Addresses & Desired Distributions
DISTRIBUTION
I would like my Entire Residuary Estate to go to
Please specify who you would like to inherit from you (ex. "split equally between my children")
Do you wish to bequest any specific items? (jewelry, cars, personal items)

No, these items pass as part of my residuary estateYes, I would like to make the following bequests:
Specify the Item(s) and the Recipient(s)
If One Of Your Children Pre-deceases You, How Should His / Her Share Be Distributed?

Per Stirpes : His/Her share will be divided equally among his/her children (your grandchildren)Per Capita: His/Her share will be divided equally among his/her siblings (your other children) *note* the children of the predeceased child (your grandchildren) will receive nothing
What Age Must Beneficiaries Be To Receive Their Shares?
Select One (1)
EXECUTOR/EXECUTRIX
Primary Choice

First NameMiddle NameLast Name
MaleFemaleOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Successor (Back Up)

First NameMiddle NameLast Name
MaleFemaleOther
Successor (Back Up) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Successor (Back Up) Phone Number

Area CodePhone Number
If A Minor Grandchild Becomes A Beneficiary

The executor has discretion whether to release any bequestA trust must be created as follows:
Trustee Name

First NameMiddle NameLast Name
Trustee Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Trustee Phone Number

Area CodePhone Number
HEALTH CARE PROXY

[only complete if requesting a Health Care Proxy]
Proxy (the person you are trusting with your health decisions)

First NameMiddle NameLast Name
Proxy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Proxy Phone Number

Area CodePhone Number
Successor (Back Up) Proxy

First NameMiddle NameLast Name
Successor (Back Up) Proxy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Successor (Back Up) Proxy Phone Number

Area CodePhone Number
This Health Care Proxy to remain in effect :
Select One (1)
Specify Date or Condition for Expiration
POWER OF ATTORNEY

[only complete if you are requesting a power of attorney]
How Many Agents Are You Authorizing To Act On Your Behalf?

12
May These Agent(s) Act Separately?

Yes *recommendedNo
Agent #1 (the person you are giving authority to act on your behalf)

First NameMiddle NameLast Name
Agent #1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agent #1 Phone Number

Area CodePhone Number
Agent #2 (the person you are giving authority to act on your behalf)

First NameMiddle NameLast Name
Agent #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agent #2 Phone Number

Area CodePhone Number
Successor (Back Up) Agent #1

First NameMiddle NameLast Name
Successor (Back Up) Agent #1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Successor (Back Up) Agent #1 Phone Number

Area CodePhone Number
Successor (Back Up) Agent #2

First NameMiddle NameLast Name
Successor (Back Up) Agent #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Successor (Back Up) Agent #2 Phone Number

Area CodePhone Number
Do You Wish To Revoke Any Prior Powers Of Attorney?

YesNo
What Authority Would You Like To Give To Your Agent(s)?

(A) real estate transactions;(B) chattel and goods transactions;(C) bond, share and commodity transactions;(D) banking transactions;(E) business operating transactions;(F) insurance transactions(G) estate transactions;(H) claims and litigation;(I) personal and family maintenance. If you grant your agent this authority, it will allow the agent to make gifts that you customarily have made to individuals, including the agent, and charitable organizations. The total amount of all such gifts in any one calendar year cannot exceed five hundred dollars;(J) benefits from governmental programs or civil or military service;(K) health care billing and payment matters; records, reports and statements;(L) retirement benefit transactions;(M) tax matters;(N) all other matters;(O) full and unqualified authority to my agent to delegate any or all of the foregoing powers to any person or persons whom my agent(s) select;ALL of the above matters identified by the following letters: A, B, C, D, E, F, G, H, I, J, K, L, M, N and O (You do not need to initial the other lines if you select this option).
Is Your Agent(s) Authorized To Make Monetary Gifts In Excess of $500 per year?

YesNo
Should Your Agent(s) Receive Compensation?

YesNo
Monitor
Select One (1)
Monitor Name

First NameMiddle NameLast Name
Monitor Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Monitor Phone Number

Area CodePhone Number
DISPOSITION OF REMAINS

[only complete if you are appointing an agent to control your remains]
Agent (the person you are trusting to dispose of your remains)

First NameMiddle NameLast Name
Agent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agent Phone Number

Area CodePhone Number
Successor (Back Up) Agent

First NameMiddle NameLast Name
Successor (Back Up) Agent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Successor (Back Up) Agent Phone Number

Area CodePhone Number
Do You Wish To Express Your Funeral Arrangement Preference?
Select One (1)
Specify Gravesite Name & Location
Are These Arrangements Already Paid For?
Select One (1)
Funeral Firm Name / Address / Phone Number
Describe Any Special Directions Limiting The Power Granted To Your Agent, As Well As Any Instructions Or Wishes Desired To Be Followed In The Disposition Of Your Remains
May Your Agent Donate Your Organs?

YesNo
IRREVOCABLE TRUSTS

[only complete if you are requesting an irrevocable trust]
Trustee (the person responsible for enforcing the terms of the trust)

First NameMiddle NameLast Name
Trustee Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Trustee Phone Number

Area CodePhone Number
Successor (Back Up) Trustee

First NameMiddle NameLast Name
Successor Trustee Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Successor Trustee Phone Number

Area CodePhone Number
How Many Properties Would You Like To Put Into The Irrevocable Trust?
Property #1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Property #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Property #3 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Properties
Please locate a copy of each (i) property deed, and (ii) recent property tax bill. We will be reaching out for these items to complete the deed transfer documents.
ADDITIONAL COMMENTS / CONCERNS
I would like a :

Last Will & TestamentPower of AttorneyHealthcare ProxyIrrevocable TrustDisposition of Remains
Should be Empty:

GULOTTA & GULOTTA, PLLC

ESTATE PLANNING QUESTIONNAIRE