Questionnaire

Bold labels and This graphic indicates a required field. indicate required information.

Personal Information
Personal Information

(Use full legal name. Use “JT” if both spouses are the parents, “H” if husband is the parent, “W” if wife is the parent, “S” if a single parent.)

Advisors
Your Concerns

Please rate the following as to how important they are to you:
(H high concern, S some concerned, L low concern, N/A no concern or not applicable)


















Important Family Questions

(Please check “Yes” or “No” for your answer)

Are you (or your spouse) receiving Social Security, disability, or other governmental benefits?

Are you (or your spouse) making payments pursuant to a divorce or property settlement order? Please furnish a copy at your next in office visit.

If married, have you and your spouse signed a pre or postmarriage contract? Please furnish a copy at your next in office visit.

Have you (or your spouse) been widowed? If a federal estate tax return or a state death tax return was filed, Please furnish a copy at your next in office visit.

Have you (or your spouse) ever filed federal or state gift tax returns? Please furnish copies of these returns

Have you (or your spouse) completed previous will, trust, or estate planning? Please furnish copies of these documents

Do you support any charitable organizations now that you wish to make provisions for at the time of your death? If so, please explain below.

Are there any other charitable organizations you wish to make provisions for at the time of your death? If so, please explain below.

If married, have you lived in any of the following states while married to each other? Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, or Wisconsin

Are you (or your spouse) currently the beneficiary of anyone else’s trust? If so, please explain below.

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

Do any of your children receive governmental support or benefits?

Do you provide primary or other major financial support to adult children or others?


Property Information Instructions for completing the Property Information checklist:

General Headings

This Property Information checklist helps you list all the property you own and what it is worth. If you do not own property under a particular heading, just leave that section blank. Under certain headings, you may own more property than can be listed on this checklist. If so, attach extra sheets of paper to list your additional property.

Type

Immediately after the heading for each kind of property is a brief explanation of what property you should list under that heading

“Owner” of Property

How you own your property is extremely important for purposes of properly designing and implementing your estate plan. For each property, please indicate how the property is titled. When doing so, please use the following abbreviations:

Owner of Property

Please Use the Following

If married, Wife’s name alone, with no other person

W

If married, Joint Tenancy with spouse

JTS

If you cannot determine how the property is owned

?

Real Property

TYPE: Any interest in real estate including your family residence, vacation home, timeshare, vacant land, etc.









Furniture and Personal Effects

TYPE: List separately only major personal effects such as jewelry, collections, antiques, furs, and all other valuable non-business personal property (indicate type below and give a lump sum value for miscellaneous, less valuable items.).






Automobiles, Boats, and RVs

TYPE: For each motor vehicle, boat, RV, etc. please list the following: description, how titled, market value and encumbrance:

Bank Accounts

TYPE: Checking Account “CA”, Savings Account “SA”, Certificates of Deposit “CD”, Money Market “MM” (indicate type below). Do not include IRAs or 401(k)s here





Note: If Account is in your name (or your spouse’s name) for the benefit of a minor, please specify and give minor’s name.

Stocks and Bonds

TYPE: List any and all stocks and bonds you own. If held in a brokerage account, lump them together under each account. (indicate type below)






Life Insurance Policies and Annuities

TYPE: Term, whole life, split dollar, group life, annuity. ADDITIONAL INFORMATION: Insurance company, type, face amount (death benefit), whose life is insured, who owns the policy, the current beneficiaries, who pays the premium, and who is the life insurance agent.



Retirement Plans

TYPE: Pension (P), Profit Sharing (PS), H.R. 10, IRA, SEP, 401(K). ADDITIONAL INFORMATION: Describe the type of plan, the plan name, the current value of the plan, and any other pertinent information.



Business Interests

TYPE: General and Limited Partnerships, Sole Proprietorships, privately-owned corporations, professional corporations, oil interests, farm, and ranch interests. ADDITIONAL INFORMATION: Give a description of the interests, who has the interest, your ownership in the interests, and the estimated value of the interests.



Money Owed To You

TYPE: Mortgages or promissory notes payable to you, or other moneys owed to you


Anticipated Inheritance, Gift, or Lawsuit Judgment

TYPE: Gifts or inheritances that you expect to receive at some time in the future; or moneys that you anticipate receiving through a judgment in a lawsuit. Describe in appropriate detail.

Other Assets

TYPE: Other property is any property that you have that does not fit into any listed category.




Summary of Values

Assets












Note: Joint Property values enter 1/2 in husband’s column and 1/2 in wife’s column.
Design Information PERSONS TO ACT FOR YOU:

GUARDIAN FOR MINOR CHILDREN: If you have any children under the age of 18, list in order of preference who you wish to be guardian.

INITIAL TRUSTEE(S): Usually the Maker will be the Trustee of his or her own trust. Often, both spouses, jointly. Allows you to continue to jointly control your assets as before.

DISABILITY TRUSTEE: If you were unable to make decisions for yourself, who would you want to make decisions for you with regard to your property and assets?

FOR HUSBAND

FOR WIFE

DEATH TRUSTEE: After your death, who do you want carrying out your instructions, for distribution to and, if desired, management of property for your beneficiaries?

FOR HUSBAND

FOR WIFE

DISTRIBUTIONS OF PERSONAL PROPERTY AND SPECIFIC GIFTS

USE OF PERSONAL PROPERTY MEMORANDUM: Do you want to provide that your personal property will be distributed pursuant to a written list you may prepare later?

Any property not listed on the memorandum should be distributed to:

FOR HUSBAND:


FOR WIFE:

SPECIFIC GIFTS: List any specific gifts of real estate or cash gifts you wish to make to either individuals or charities. Indicate whether these gifts are to be made even if the other spouse is alive.

FOR HUSBAND:

FOR WIFE:

Division of property upon death of first spouse

Division of property upon death of second spouse to die

How and when to distribute my property:

REMOTE CONTINGENT BENEFICIARY: Who do you want to receive your property in the remote event that no one listed above is alive to receive your property. Determining the remote contingent beneficiary is not so important that it should cause you to delay completion of your entire estate plan. It can always be changed at a later date.

In the remote event no one listed above is alive to receive my property I want my property distributed as follows:

POWER OF ATTORNEY:

If you were unable to make financial decisions for yourself, who would you want to Page 12 make those decisions for you?

HUSBAND’S AGENT

WIFE'S AGENT

HEALTH CARE:

If you were unable to make decisions for yourself, who would you want to make decisions for you with regard to your medical treatment?

HUSBAND’S AGENT

WIFE'S AGENT

How Can We Help You?

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