Information Checklist

Please fill out Information Checklist online as completely as possible and then click SUBMIT at the bottom of the form. After you press SUBMIT, you will receive an email with a copy of the Information Checklist for you to print for your records (make sure you provide an email address in the checklist).

If you need more time to fill out the questions, go ahead and SUBMIT an incomplete form and you will receive an email with a link to go back and finish completing the form (make sure you provide an email address in the checklist and check your email / spam folder for a "confirmation of submission").

** Please do not PRINT this checklist using Ctrl-P or the PRINT button on your browser because additional questions will appear based on your online answers (for example - "Are you married" or "Do you have children" will prompt additional questions to appear) so it is important that you answer all questions online. **

Please submit your Information Checklist at least 24 hours in advance of your meeting. Otherwise, please bring a printed copy to your meeting.

If you prefer to print and fill out the Information Checklist by hand, please click here for a PDF of the Information Checklist to print and fill out manually and bring to your meeting.

Date this form was filled out

MonthDayYear

My Name

(the above name will be used in your documents - exactly how it is spelled above)

Full Legal Name

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

County

Home Phone Number

Area CodePhone Number

Cell Phone Number

Area CodePhone Number

Birthdate

MonthDayYear

E-mail*

Confirmation Email

US Citizen?

US CitizenNon-US Citizen

Occupation

Company Name

Work Street Address

Work Phone

Are you married? *

YesNo

My Spouse's Name

(the above name will be used in your documents - exactly how it is spelled above)

My Spouse's Full Legal Name

Birthdate

MonthDayYear

E-mail

Home Phone Number

Area CodePhone Number

Cell Phone Number

Area CodePhone Number

US Citizen?

US CitizenNon-US Citizen

Occupation

Company Name

Work Street Address

Work Phone

Wedding Anniversary Date

MonthDayYear

Do you have children?*

YesNo

Child 1 Name

Choose one

Birthdate

MonthDayYear

Address

Grandchildren?

YesNo

List Grandchildren

Child 2 Name

Choose one

Birthdate

MonthDayYear

Address

Grandchildren?

YesNo

List Grandchildren

Child 3 Name

Choose one

Birthdate

MonthDayYear

Address

Grandchildren?

YesNo

List Grandchildren

Child 4 Name

Choose one

Birthdate

MonthDayYear

Address

Grandchildren?

YesNo

List Grandchildren

Do you have additional children?

YesNo

Child 5 Name

Choose one

Birthdate

MonthDayYear

Address

Grandchildren?

YesNo

List Grandchildren

Child 6 Name

Choose one

Birthdate

MonthDayYear

Address

Grandchildren?

YesNo

List Grandchildren

Child 7 Name

Choose one

Birthdate

MonthDayYear

Address

Grandchildren?

YesNo

List Grandchildren

Child 8 Name

Choose one

Birthdate

MonthDayYear

Address

Grandchildren?

YesNo

List Grandchildren

Are any of your children under 18?

YesNo

Guardian #1

Guardian #2

Guardian #3

Guardian #4

Do you have grandchildren?

YesNo

Parent Name

List Grandchildren

Parent Name

List Grandchildren

Parent Name

List Grandchildren

Parent Name

List Grandchildren

Parent Name

List Grandchildren

Parent Name

List Grandchildren

Parent Name

List Grandchildren

Parent Name

List Grandchildren

Do you have any deceased children?

YesNo

Deceased Child's Name

Descendants?

YesNo

List Descendants

Deceased Child's Name

Descendants?

YesNo

List Descendants

Deceased Child's Name

Descendants?

YesNo

List Descendants

Are there other people dependent on you?

YesNo

Details

Do you have any stored genetic material?

YesNo

Details

Do any of your children have stored genetic material?

YesNo

Details

Do you have any pets?

YesNo

Details

Do you want to make special provisions for your pets?

YesNo

Details

What documents do you have now?

What state is your legal residence?

Do any of your children have special educational, medical or physical needs?

YesNo

Details

Do any of your children receive SSI, SSDI, Medicaid?

Are any of your children adopted?

YesNo

Details

Have you ever made a gift exceeding the gift tax exemption?

YesNoI don't know

Details

Are you enrolled in the Senior Citizens Real Estate Tax Deferral Program?

YesNoI don't know

Do you have long-term health care insurance?

YesNo

Details

Do you own any firearms?

YesNo

Do you have a FOID card?

YesNo

Does your spouse have a FOID card?

YesNo

Have you ever been divorced?

YesNo

I have been divorced.My spouse has been divorced.We both have been divorced.

Details

Have you ever signed a pre- or post-marital agreement?

YesNo

I have signed an agreement.My spouse has signed an agreementWe both have signed an agreement.

Details

Have you ever inherited property from someone?

YesNo

I have inherited property.My spouse has inherited property.We both have inherited property.

Details

Do you own real estate in a state other than IL?

YesNo

Details

Do you want to disinherit anyone?

YesNo

Details

What charities do you donate to now?

Do you want to contribute to charity upon death?

YesNoMaybe

Details

Health Care Agents - to make medical decisions for you in case you cannot do so yourself

Health Care Agents for:

Health Care Agent #1

Agent 1's Phone

Area CodePhone Number

Health Care Agent #2

Agent 2's Phone

Area CodePhone Number

Health Care Agent #3

Agent 3's Phone

Area CodePhone Number

Health Care Agent #4

Agent 4's Phone

Area CodePhone Number

Health Care Agents - to make medical decisions for you if you cannot do so yourself

Health Care Agents for:

Health Care Agent #1

Agent 1's Phone

Area CodePhone Number

Health Care Agent #2

Agent 2's Phone

Area CodePhone Number

Health Care Agent #3

Agent 3's Phone

Area CodePhone Number

Health Care Agent #4

Agent 4's Phone

Area CodePhone Number

Incapacity Trustees - if you were incapacitated, who would you want to pay your bills, manage your money, etc.

Incapacity Trustees for:

Incapacity Trustee #1

Incapacity Trustee #2

Incapacity Trustee #3

Incapacity Trustee #4

Incapacity Trustee #5

Corporate Trustee Backup

Comments

Incapacity Trustees - if you were incapacitated, who would you want to pay your bills, manage your money, etc.

Incapacity Trustees for:

Incapacity Trustee #1

Incapacity Trustee #2

Incapacity Trustee #3

Incapacity Trustee #4

Incapacity Trustee #5

Corporate Trustee Backup

Comments

Death Trustees - when you pass away, who would you want to pay your bills, gather your assets, and distribute your assets

Death Trustees for:

Death Trustee #1

Death Trustee #2

Death Trustee #3

Death Trustee #4

Death Trustee #5

Corporate Trustee Backup

Comments

Death Trustees - when you pass away, who would you want to pay your bills, gather your assets, and distribute your assets

Death Trustees for:

Death Trustee #1

Death Trustee #2

Death Trustee #3

Death Trustee #4

Death Trustee #5

Corporate Trustee Backup

Comments

Do you want to allow each beneficiary to be sole Trustee of their separate trust share?

YesNoNot Applicable

At what age?

Asset Summary

Joint Bank Accounts

Joint Real Estate

Joint Investment Accounts

Assets belonging to:

Real Estate

Bank Accounts

Investment Accounts

Life Insurance

IRA's / 401k's

Personal Property

Other

Assets belonging to:

Real Estate

Bank Accounts

Investment Accounts

Life Insurance

IRA's / 401k's

Personal Property

Other

Comments or details

Liability Summary

Joint Mortgages

Joint Auto Loans

Liabilities belonging to:

Mortgages

Auto Loans

Student Loans

Liabilities belonging to:

Mortgages

Auto Loans

Student Loans

Comments or details

Who should receive your estate when you pass away?

Questions or Comments

Click the box*

Click SUBMIT to send this form to Kuczek & Associates.

If you provided an email address in the checklist, you will receive an email with the Information Checklist to print for your records, and a link in case you want to go back and add information or make changes to the Information Checklist (check your email / spam folder for a "confirmation of submission").