ESTATE & LONG TERM CARE PLANNING QUESTIONNAIRE

Law Offices of Cheryl L. Walsh, APC
27282 Calle Arroyo, Suite 200
San Juan Capistrano, CA 92675
Phone: (949) 240-9003 Fax: (949) 240-9083
Cheryl@WalshSeniorLaw.com
ESTATE & LONG TERM CARE PLANNING QUESTIONNAIRE
Please complete the questionnaire. If there is a request for information that does not pertain to you, please write "N/ A". The information that you provide will help us to more accurately assess your estate and long term planning needs and will be confidential. We will discuss the information provided during our initial consultation and recommendations will be made on that basis.
PERSONAL INFORMATION
YOU
Name:
Date of Birth:
Social Security #
Address:
Veteran?
Telephone #:
Burial Arrangements:
YOUR SPOUSE
Name:
Date of Birth:
Social Security #
Address:
Veteran?
Telephone #:
Burial Arrangements:

MARITAL INFORMATION
Date and Place of Marriage:
Name of Prior Spouse (if applicable):
Date of Divorce (if applicable):
Date of Spouse's Death (if applicable):
INCOME

List all monthly income for you and your spouse:
#1
Source of Income:
Amount:
#2
Source of Income:
Amount:
#3
Source of Income:
Amount:
#4
Source of Income:
Amount:
#5
Source of Income:
Amount:
#6
Source of Income:
Amount:
#7
Source of Income:
Amount:
#8
Source of Income:
Amount:

EXPENSES

List all monthly expenses for you and your spouse:
#1
Expense:
Amount:
#2
Expense:
Amount:
#3
Expense:
Amount:
#4
Expense:
Amount:
#5
Expense:
Amount:
#6
Expense:
Amount:

ASSETS

List all assets owned by you and/or your spouse:
REAL ESTATE
Address:
Name on Deed (title):
Assessor's Parcel Number (see property tax bill for APN):
Date of Purchase:
Purchase Price:
Current Fair Market Value:
Amount Owed:
Lender:
Home Equity Loan?Lender:
Reverse Mortgage?

LIFE INSURANCE POLICIES
#1
Policy Owner:
Beneficiary:
Whole Life/Term:
Face Value:
Cash Value:
Insurance Company:
#2
Policy Owner:
Beneficiary:
Whole Life/Term:
Face Value:
Cash Value:
Insurance Company:
#3
Policy Owner:
Beneficiary:
Whole Life/Term:
Face Value:
Cash Value:
Insurance Company:
#4
Policy Owner:
Beneficiary:
Whole Life/Term:
Face Value:
Cash Value
Insurance Company:

ANNUITIES, SECOND TRUST DEEDS, PROMISSORY NOTES
#1
Owner:
Description:
Beneficiary(ies):
Value:
#2
Owner:
Description:
Beneficiary:
Value:
#3
Owner:
Description:
Beneficiary:
Value:
#4
Owner:
Description:
Beneficiary:
Value:
#5
Owner:
Description:
Beneficiary:
Value:

PERSONAL PROPERTY
Automobiles
#1
Year:
Make:
Model:
How is title held?
#2
Year:
Make:
Model:
How is title held?:
#3
Year:
Make:
Model:
How is title held?

Valuable Artworks (list, describe)
Collectibles/Antiques (list, describe)
Safe Deposit Boxes
#1
Location:
Box #:
Authorized Entrants:
#2
Location:
Box #:
Authorized Entrants:

BUSINESS OWNERSHIP/INTERESTS (CORPORATION, LLC, PARTNERSHIP, ETC.)
#1
Name of Business:
Type of Ownership:
% Owned:
#2
Name of Business:
Type of Ownership:
% Owned:
#3
Name of Business:
Type of Ownership:
% Owned:
#4
Name of Business:
Type of Ownership:
% Owned:
#5
Name of Business:
Type of Ownership:
% Owned:
#6
Name of Business:
Type of Ownership:
% Owned:
MISCELLANEOUS ADDITIONAL ASSET INFORMATION (include any additional information):

LIABILITIES

List monies owned by you and/or your spouse:
Creditor:
Amount Owed:
Amount & Frequency of Payments:
Creditor:
Amount Owed:
Amount & Frequency of Payments:
Creditor:
Amount Owed:
Amount & Frequency of Payments:
Creditor:
Amount Owed:
Amount & Frequency of Payments
Creditor:
Amount Owed:
Amount & Frequency of Payments:
Creditor:
Amount Owed:
Amount & Frequency of Payments:
Creditor:
Amount Owed:
Amount & Frequency of Payments:
Creditor:
Amount Owed:
Amount & Frequency of Payments:

PROFESSIONAL INFORMATION
Who referred you to our office?
Have you consulted with another attorney prior to your visit?
If so, what is the name of the prior attorney?
Do you have a regular CPA?
If so, who is your regular CPA?
Do you have a financial advisor?
What is your financial advisor's name & contact information?
What is the reason for your visit?
Thank you for taking the time to complete the questionnaire.
Should be Empty: