Estate Planning Questionnaire
Individual
All information provided is confidential. Please provide names, addresses, phone numbers and/or relationship where asked (will be shown under question). Please include addresses and phone numbers where requested for all agents.
If you are completing this form on behalf of someone else please provide your contact information and relationship here:
Full Name:
*
Date of birth:
/
Month
/
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of Residence:
Home Phone:
Cell Phone:
Place of Employment (or former employment if retired):
Email address:
*
example@example.com
Did anyone refer you to us?
Yes
No
If yes, whom may we thank?
What topics do you want to discuss at your appointment?
*
Do you have any deceased children?
Yes
No
If yes, specify below and list any living descendants of such child(ren):
Please list any children, their age and gender
Describe how you would like your estate distributed upon your death:
*
All to spouse, then to descendants (children)
All to descendants, shared equally
Different shares to different people and/or charities
All to charity
Other
Please list any specific gifts you'd like to give to anyone at your passing:
Who do you want to name as the Personal Representative(s) of your estate (to administer your will after your death)
*
2nd Alternate Personal Representative
3rd Alternate Personal Representative
Do you want to provide your Personal Representative(s) and/or Trustee(s) reasonable compensation?
Yes
No
If you would like to disinherit anyone please list their name and relationship to you:
Who do you want to name as the Guardian(s) of your children (if you have children under age 18) (Note: two persons may serve together as long as they are married)
Name(s) and Relationship(s)
2nd Alternate Guardian(s)
Name(s) and Relationship(s)
3rd Alternate Guardian(s)
Name(s) and Relationship(s)
Would you like to create a Trust?
*
Yes
No
If yes, who do you want to name as Trustee(s)
Name(s)
2nd Alternate Trustee(s)
Name(s)
3rd Alternate Trustee(s)
Name(s)
If leaving assets to descendants in trust please choose a distribution schedule:
Held in trust for lifetime of beneficiaries; next generation until a specified age
Held in trust for beneficiaries with a lump sum at a specified age
1/2 at specified age or event; balance at specified age
1/3 at specified age or event; 1/2 at specified age or event; balance at specified age
Other
If distribution will happen at a specified age or event please indicate that age(s) and or event(s) here:
Who do you want to name as agent(s) of your Durable Power of Attorney? (A Durable Power of Attorney gives the person(s) named the power to sign your name if you are unable to do so):
*
Name(s) and Address(es)
2nd Alternate Agent
Name and Address
3rd Alternate Agent
Name and Address
Would you like any of your Agents to serve together?
Yes
No
If yes, would you like them to act together or will they be able to act separately?
Must act together
May act seperately
Decisions must be unanimous
Who do you want to name as agent(s) on your Designation of Health Care Surrogate (A Health Care Surrogate gives the person(giving another person the power to make healthcare decisions for you)
*
Name(s), Address(es) & Phone Number(s)
2nd Alternate Agent
Name, Address & Phone Number
3rd Alternate Agent
Name, Address & Phone Number
Would you like any of your agents to serve together?
Yes
No
If yes, would you like them to act together or will they be able to act separately?
Must act together
May act seperately
Decisions must be unanimous
Please indicate your preference
Burial
Cremation
No Preference
Do you have specific burial instructions?
Do you own a home in Florid and if yes, is it your primary residence?
Yes
No
Finally, please list your assets and approximate value (other than your Florida homestead)
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