Client Form

Estate Planning Client Questionnaire

BELLAS & WACHOWSKI ATTORNEYS AT LAW CONFIDENTIAL PERSONAL & FINANCIAL INFORMATION©
We offer this questionnaire to our estate planning clients to assist us in guiding you through the estate planning process. This information will help us in evaluating your current situation and requirements, and help us create a plan that is best suited for your individual needs. All information will be kept confidential.
A. Background Information

Enter your information, then your spouse's information.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Place of Birth
U.S. Citizen?

YesNo
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address
Facebook
LinkedIn
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Employer's Name
Work Address

Street Address

Street Address Line 2

CityState / Province

Zip CodeCountry
Spouse Name

First NameLast Name
Date of Birth

MonthDayYear
Place of Birth
U.S. Citizen?

YesNo
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address
Facebook
LinkedIn
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Employer's Name
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you at any time during your marriage resided in a community property state?
- If yes, where and when? Type a label
Have you and your spouse entered into any agreement prior to or during your marriage regarding the rights of each of you in the property of the other? Yes No

B. Children
Child One
Name

First NameLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Marital Status
Number of Children
Child Two
Name

First NameLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Marital Status
Number of Children
Child Three
Name

First NameLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Marital Status
Number of Children
Is any Child adopted? Yes No
- If yes, please provide the following information:
Name of Adopted Child

First NameLast Name
Date of Birth

MonthDayYear
Date of Adoption

MonthDayYear
Place of Adoption (City, State, and Country)
Did any Child(ren) die before this time? Yes No
- If yes, please provide the following information:
Name of Child

First NameLast Name
Date of Birth

MonthDayYear
Date of Death

MonthDayYear
Did any Child or Grandchild have a Special Need due to a Physical or Mental condition? Yes No
- If yes, please provide the following information:
Name

First NameLast Name
Relationship
Condition
C. Additional Information
Is there any other information we should know about you or your family? (e.g. second marriage, etc.)

D. Personal Representatives
(i) Executor: Please provide the name of individual (or bank with a trust department) that you wish to be the executor of your will. The executor is the person who generally makes the funeral arrangements, collects life insurance proceeds and final paychecks, pays the debts, files tax returns and affidavits (when needed) and in general winds up the affairs of the deceased person. The basic requirement is that you name a U.S. citizen over the age of 18, mentally competent and who will probably be alive at the time of your death. The executor must be an individual who has never been convicted of a felony.

Please name 2 candidates.
If filling out the form as a married couple, use both executor sections. If filling out the form as single/divorced/widowed, please only fill out the executor section for First Member.

Note: Spouse is recommended as the first candidate for married couples. Example: John and Jane Doe are married. John Doe is filling out the form for himself and Jane. He would put Jane Doe as Name 1 for First Member and she would put John Doe as Name 1 for Spouse.
Name 1 for First Member

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name 2 for First Member

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name 1 for Spouse

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name 2 for Spouse

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(ii) Guardian For Your Minor Child(ren): This is necessary if you have minor children (under the age of 18) and will take effect if both parents die. Guardians must be over 18 and mentally competent. Try to name a 1st and 2nd choice. You can name one person or a married couple. You do not need to name a relative. You should try and name someone who has the same philosophy and style of raising children as you do.
Name 1

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name 2

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(iii) Trustee (of a Trust): May be the same person as Executor or another individual, over 18 who is competent, or a Trust Company.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Successor Trustee (if the Trustee cannot or refuses to act):
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(iv) Trustee of Child(ren)’s Trust (if applicable): May be the same person as Executor or another individual, over 18 who is competent, or a Trust Company.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Successor Trustee (if the Trustee cannot or refuses to act):
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(v) Powers of Attorney:

Power of Attorney for Healthcare: The person named here will make decisions about your medical care if you are unable to do so for any reason. May be an individual, typically a spouse. If the primary agent is unavailable or unwilling to make the decision, you must name a successor agent.
Name of Agent

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Successor Agent:
Name of Successor Agent

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E. Professional Relationships
(i) Accountant
Name

First NameLast Name
Accounting Firm
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
(ii) Life Insurance Representative/Agent
Name

First NameLast Name
Firm
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
(iii) Investment Advisor
Name

First NameLast Name
Investment Firm
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

F. Financial Information

	Husband	Wife	Joint
Cash
Bank Accounts
Certificates of Deposit
Mutual Funds
Brokerage Home Accounts
Stocks
Gov. Savings Bonds (Series E, H, EE, HH)
Tax Free Bonds
Individual Retirement Account
Qualified or Nonqualified Employer Plans
Annuities
Life Insurance (Face Value/Death Benefit)
Real Estate (Include Primary Residence, Vacation Homes, Rental Property, Vacant Land)
Passive Real Estate (e.g. Limited Partnerships, etc.)
Automobiles
Interest in Closely Held Business
Sole Proprietorship
Cryptocurrency
Personal / Misc. Assets
TOTAL ASSETS

Liabilities

	Husband	Wife	Joint
Long-term (Mortgage or Notes not to be repaid within 1 year)
Other Liabilities

Net Worth

	Husband	Wife	Joint
Net Worth

G. To Whom Do You Want the Estate to Go Upon Your Death(s)
Name 1

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Minor?
Percentage
Per Stirpes?
Name 2

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Minor?
Percentage
Per Stirpes?
SPECIAL REQUESTS/GIFTS: Are there any gifts of specific property (e.g. family heirloom, jewelry, collections, etc.) or cash that you would like to go to a specific individual or organization, including charitable bequests?)

G. Terms of Child(ren)'s Trust
1. Principal of Child(ren)’s Trust: Until the trust is distributed to the child or children, the Trustee is typically instructed to pay only so much of the principal of the trust as is necessary for each child’s health, maintenance, in reasonable comfort, education (including post-graduate), and best interests.
If, for some reason you do not desire this language, please indicate below and explain your desires:
2. Income from Child(ren)’s Trust: Until the trust is distributed, the principal of the trust will generally earn income. The trust can be drafted so that the income is either rolled into the principal (the most common alternative) or so that the income, or at least a portion of it, is paid to the child or children on a consistent (e.g. quarterly) basis. Indicate your wishes below:
Roll Income over into Principal.

Pay Type a label % of the Income to Each Child Beginning at Age Type a label .
3. Principal Distribution of Child(ren)’s Trust: Ultimately, the principal of the trust must be distributed to the child or children. Although the balance may be distributed in one lump sum upon a child’s attaining a specific age, typically distribution is done in two or three installments (e.g. one third at age 21, one third at age 25, and one third at age 30) to protect the child from spending all of his/her inheritance at an early age. Indicate your wishes with respect to the principal distribution of the trust below:
1/ at Age;
1/ at Age;
1/Type a label at Age.

This questionnaire was prepared for your benefit and you are providing this information with the understanding that the information provided will be relied upon by your estate planning attorneys for your benefit. No other investigation will be conducted to confirm the information.
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A. Background Information

B. Children

C. Additional Information

D. Personal Representatives

E. Professional Relationships

F. Financial Information

G. To Whom Do You Want the Estate to Go Upon Your Death(s)

G. Terms of Child(ren)'s Trust