Estate Planning Questionnaire
Date Questionairre Completed
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Month
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Day
Year
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Your Information
Please fill information about yourself
Your Name
*
First Name
Last Name
Your Email
*
example@example.com
Your SSN
Your Date of Birth
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Month
-
Day
Year
Alternate Email
example@example.com
Are You a US Citizen?
*
Yes
No
Your Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main Phone
*
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Area Code
Phone Number
Work Phone
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Area Code
Phone Number
Mobile Phone
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Area Code
Phone Number
Fax
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Area Code
Phone Number
Spouse
Please enter information about your spouse and children
Spouse's Name
First Name
Last Name
Spouse's SSN
Spouse's DOB
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Month
-
Day
Year
Date
Is your spouse a US citizen?
Yes
No
Child Information
Please list any accounts set aside for your children's (or grandchildren's) education.
Education Account Plans
Please indicate whether any minor child has separate assets other than those listed above, including approximate value and in whose name they are held:
Family Circumstances
Please note any special family considerations (i.e., adopted children, previous marriages, special health problems of any familymembers). If a spouse is deceased, please note his or her date of death:
Your Annual Occupation and Income (USD)
Your Occupation
Your Work Income
Your Social Security Income
Your Pension Income
Your Rental Income
Your Dividend Income
Your Annuity Income
Your Other Income
Your Total Income (USD)
Spouse's Annual Occupation and Income (USD)
Spouse's Occupation
Spouse's Work Income
Spouse's Social Security Income
Spouse's Pension Income
Spouse's Rental Income
Spouse's Dividend Income
Spouse's Annuity Income
Spouse's Other Income
Spouse's Total Income (USD)
Total Income You + Spouse (USD)
Assets
Real Estate
List additional properties at end of form or attach a schedule if necessary. Provide copies of all deeds if available. If any real estate is held in trust, please provide a complete copy of the trust.
Bank Accounts, CDs, Money Market Accounts, Treasury Bills, Etc.
Stocks, Bonds, and Other Publicaly Traded Securities
Closely Held Business Interests
Retirement Plans
Other Investments (Private Equity, Stock Options, Tax Shelters, etc.)
PERSONAL PROPERTY
Approximate
Fair Market
Value
Recently
Appraised (Y/N)?
Owned By
Furniture and Household Goods:
Jewelry and Furs
Boats, Aircraft, etc.
Art and Antiques
Other Collectibles
Other Items of Significant Value
TOTAL
Life Insurance
*
Liabilities (excluding real estate mortgages and home equity loans previously identified)
Description
Balance Owned
Debtor
(A) Loans (itemize)
Loan 1
Loan 2
Loan 3
Loan 4
(B) Broker’s Margin Accounts:
(c) Alimony and Support Obligations:
(d) Charitable Pledges:
(e) Lawsuits (please explain):
(f) Other (please explain):
TOTAL
Expected Inheritances
PRIOR GIFTS: List gifts over $14,000 per year (or over $12,000 per year in 2006-2008 and over $13,000 per year in 2009 and after) to anyone individual made by you or your spouse. Please indicate whether you filed gift tax returns reporting these gifts, and if so,provide a copy of each return.
*
PLEASE PROVIDE COPIES OF YOUR MOST RECENT WILLS AND/OR TRUSTS, POWERS OF ATTORNEY,HEALTH CARE PROXIES, LIVING WILLS, PRENUPTIAL OR DIVORCE AGREEMENTS,
and, if any, other documents you would like to discuss.
Please indicate your wishes (in a general way) with regard to the disposition of your property (e.g., specific bequests, sharesfor children, ages at which you believe your children should receive property outright if at all, bequests to charity, etc.). Youmay continue on the back of this page or attach additional pages if necessary.
FIDUCIARIES:
Please indicate your choices for the following fiduciary positions below, including each person’s full name (with middle initialor middle name if used legally), address and his or her relationship to you. You should also name an alternate or successor foreach position in the event your first choice is unavailable when he or she is called on to perform his or her duties as describedbelow.An Executor administers your will, seeing that your probate property is distributed to your beneficiaries as you have indicatedin your will. An Executor’s authority ends when the probate of your estate is completed. A Guardian takes care of your minorchildren in the event you and your spouse both die before all of your children reach age 18. A Trustee administers yourtrust(s), if any, and makes distributions of trust property as you have indicated in your trust for as long as the trust is inexistence. An Attorney-in-Fact serves under your durable power of attorney and makes business and financial decisions foryou in the event you become incapacitated. A Health Care Agent serves under your health care proxy and makes decisionsregarding your health care in the event you are unable to make or communicate those decisions yourself.
List your fiduciaries:
Name
Address 1
Address Line 2
City/State/Zip
Relationship
Executor
Successor Executor
Guardian (other than spouse)
Alternate Guardian
Trustee*
Successor Trustee
Attorney-In-Fact
Alternate Attorney-In-Fact
Health Care Agent
Alternate Health Care Agent
*NOTE: In many instances, you and/or your spouse can be the primary trustee of your respective trusts. Whether or not this isyour choice, you should still think about selection of a successor Trustee to serve if/when your spouse is unable to do so.Professional Trustees (e.g. attorneys, banks, trust companies) can also be selected as Trustees.
Your Professional Advisors
Name
Address 1
Address Line 2
City/State/Zip
Relationship
CPA
Financial Planner
Insurance Advisor
Stockbroker
Other Attorney
Safe Deposit Boxes
Contents
Person(s) with Access
Their Address Line 1
Their Address Line 2
City/State/Zip
Relationship
Safe Deposit Box 1
Safe Deposit Box 2
Additional Comments or Questions
List any other information you think might assist us in developing an appropriate estate plan for you below, including anyconcerns you might have or specific questions you wish to have answered. You may continue on the back of this page or attachadditional pages if necessary
How Were You Referred to Our Office?
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