Estate Planning Questionnaire (EPQ)

Welcome to Walla Street Wealth Management, Inc. and thank you for choosing our team to advise on your estate planning.

Please complete this brief questionnaire as thoroughly as possible as the information will be required during the preparation of your documents. Once submitted, our team will review the information and will contact you for any required clarification prior to next steps.

Please note that there is a Save & Continue Later button at the bottom, if you'd like to pause and revisit completing the information. When complete, please remember to click the Submit button.

If you have questions, please contact us @ 913-543-3836.

Full Name*

First NameMiddle NameLast Name

Home Address*

Street Address

Street Address Line 2

CityState

Zip Code

Mobile Number*

Format: (000) 000-0000.

Email Address*

Date of Birth*

Marital Status*

SingleMarried

Spouse: Full Name

First NameMiddle NameLast Name

Spouse: Mobile Number

Format: (000) 000-0000.

Spouse: Email Address

Spouse: Date of Birth

Question #1: Do you currently have any estate planning documents?

YesNo

Please upload a copy of all existing estate planning documents here:

Question #2: Who are the primary AND contingent agents that you would like to make financial decisions on your behalf? (if married, please provide answers for each individual)

Please include their Name, Address, Phone, Email and Relationship to You.

Question #2a: When would you like for the agents powers to become effective?

The powers should be effective immediately after signing.The powers should become effective only if I am incapacitated (unable to make decisions for myself).

Question #3: Who are the primary AND contingent agents that you would like to make health/medical decisions on your behalf? (if married, please provide answers for each individual)

Please include their Name, Address, Phone, Email and Relationship to You.

Question #4: Do you currently have minor children (under age 18)?

YesNo

Please provide each minor's full name. Also provide the name, address, phone, and email for each of the minor’s legal parents?

In the event of death, who would you like to be the Primary Guardian of your minor children? Please also include at least two (2) contingent guardians as well.

Please provide the Name, Address, Phone and Email for each guardian to be listed.

In the event of the death, would you like the minor beneficiary(s) assets to be held in sub-trust until the minor reaches a specified age?

No, please distribute assets at earliest convenience.Yes, please hold assets in subtrust until age 21.Yes, please hold assets in subtrust until age 25.Yes, please hold assets in subtrust until age 30.Yes, please hold assets in subtrust until age 35.

Question #5: Do you own any real estate assets? (house, condo, farm, vacation club, vacant land, timeshare, etc.)

YesNo

Please provide additional details on your real estate assets. This should include the address, location, and/or ownership number of the assets.

If any of the real estate assets above are held in an LLC, please provide the LLC's full legal name and Tax ID#.

Question #6: In the event of death, who would you like to be the beneficiary(s) of your estate?

Please provide their Name, Address, Phone, Email, Relationship to You, and % of the estate. Total % must add up to 100%.

Question #7: Would you like to include any specific cash bequests prior to distributing the remainder of your estate to your beneficiary(s)?

Specific cash bequests are usually lump-sum cash gifts to friends, family or charities.

Question #8: In the event that you have a terminal health condition (one from which there is no likelihood of recovery) to what extent would you like to receive life supporting services?

Life supporting services may include breathing tube, feeding tube, dialysis, defibrillation, etc.

Question #8a: Under which circumstances do you want life support to be discontinued? (select all that apply)

If I am persistently or permanently unconscious.If there is no reasonable expectation of my recovery from a seriously incapacitating or terminal illness or condition.

Question #9: Would you like to provide any preferences about the handling of your remains, funeral plans, or final resting place?

This may include pre-paid burial plans, burial vs cremation, cemetery location, spreading of ashes, etc.

Question #10: In the event of death, would you like to be an organ donor?

YesNo

Would you prefer to be an organ donor for Medical Purposes only OR for both Medical and Research Purposes?

Medical Purposes OnlyMedical and Research Purposes

Question #9: Would you prefer to be an organ donor? If Yes, would you prefer to be a donor for Medical Purposes only OR both Medical Purposes and Research Purposes?

Question #11: Do you have any pets?

YesNo

Please provide your wishes about the caretaking of your pets. This should include naming a pet guardian and what amount of financial resources ($) will be provided for the pet’s care.

Question #12: Please list any physical assets that you would like to leave to specific individuals.

This may include items such as automobiles, furniture, jewelry, keepsakes, artwork, collectibles, etc.

Thank you for completing the Estate Planning Questionnaire (EPQ). You may Print your completed information, Save & Continue Later if you'd like to revisit this form, or Submit your completed information directly to your advisor.