CONFIDENTIAL ESTATE PLANNING QUESTIONNAIRE

If you have any issues with this form please call the main office: 704-596-3200 and ask for Trust Services or send an email to trust@carolinasda.org

Interviewer:

Membership:

Today's Date

Date

Prior File

Provide FULL LEGAL names when required.

Mr:

Date of Birth:

Date

# of Marriages:

Occupation:

Marital Status:

(If widowed, provide name & date of death of former spouse)

Miss/Ms/Mrs:

Date of Birth:

Date

# of Marriages:

Occupation:

Marital Status:

(If widowed, provide name & date of death of former spouse)

Street Address:

City:

State:

Zip:

County:

Home Phone:

Email:

example@example.com

His Cell:

Her Cell:

Please list all children, living or deceased, whether or not they will receive from your estate. Omitted children can contest a Will.

Rows	Name:	Indicate: His/Hers/Ours:	Age:

Do you plan to have more children?

After the death of both you and your spouse, who would you appoint to have physical custody and care of your minor (younger than 18)children? (Provide Guardian and Trustee's contact information in notes area on page 2)

Guardian 1st Choice:

Guardian 2nd Choice:

Who would you appoint to manage and distribute any property placed in trust for your minor children?

Trustee 1st Choice:

Trustee 2nd Choice:

Who will distribute your estate? (Executor/Personal Representative):

Your Spouse?

*Executor/Personal Representative if not spouse:

Hist 1st Alternative:

His 2nd Alternative

Her 1st Alternative:

Her 2nd Alternative:

Who would make health care decisions for you if you are incapacitated?

Your Spouse?

*Living Will & Health Care Power of Attorney If not spouse:

His 1st Alternate:

Address:

Phone:

His 2nd Alternate:

Address:

Phone:

Her 1st Alternate:

Address:

Phone:

Her 2nd Alternate

Address:

Phone:

Who would conduct your day-to-day business, pay bills, etc.?

Your Spouse?

*General Durable Power of Attorney If not Spouse:

His 1st Alternate:

His 2nd Alternate:

Her 1st Alternate:

Her 2nd Alternate:

DISTRIBUTION OF YOUR ESTATE: It is assumed, unless you indicate otherwise, that your entire estate will pass to your surviving spouse. Describe(next page) your desired distribution after husband and wife are deceased.

All To Spouse?

Do you have a specific charitable bequest of cash or property?

Personal effects and household furnishings to be distributed: Spouse first?

The rest and residue of my estate. Spouse first?

The percentages listed below must add to 100%

% to my children in trust for their care, support, maintenance and education.

Years of age

Trust terminates when youngest reaches the above years of age.

At termination of the trust, remaining trust property passes to the children in equal shares?. In the event any child predeceases me or does not survive termination of the trust, their portion shall pass:

%

to

%

to

%

to

%

to

%

to

%

to

Do any beneficiaries have special needs (i.e. incapacitated, handicapped, in nursing home or in-homecare, receiving Social Security, Medicaid or Medicare benefits?

If yes please describe:

Is your individual gross estate valued at over $5,000,000 or $10,000,000 jointly?

Do you own real estate in any state other than your state of residence? If yes, pleaseforward a copy of the Warranty Deed and tax ID number for each piece of property in which you have an ownershipinterest, including your residence, time shares, vacation home, vacant lot, etc.

Do you have an ownership interest in a business?

If yes, please provide description orevidence of interest.

Do you have any existing Trust Agreements? If yes, please provide a copy of each documentso that we may properly coordinate with, amend or replace your existing plan.

Notes/Comments/Questions: Add any information that did not fit in previous page or describe any concern you have.

When you die, generally your Powers of Attorney terminate.