Questionnaire

Husband’s Legal Name

Also Known As

Prefer to be called

Birth date SS#

US Citizen?

Home Address

City

StateSelect StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyomingZIP

Home Telephone

County of Residence

Business Telephone

Cell Phone

Employer

Position

Business Address

City

StateSelect StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyomingZIP

Email Address

Please enter a valid email address.

It is okay to communicate with me via my Email address. Date of Marriage

Wife’s Legal Name

Also Known As

Prefer to be called

Birth date SS#

US Citizen?

Home Address

City

StateSelect StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyomingZIP

Home Telephone

County of Residence

Business Telephone

Cell Phone

Employer

Position

Business Address

City

StateSelect StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyomingZIP

Email Address

Please enter a valid email address.

It is okay to communicate with me via my Email address.

(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.)

Personal Attorney

Accountant

Financial Advisor

Life Insurance Agent

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)

Description Desire to get affairs in order and create a comprehensive plan to manage affairs in case of death or disability.HusbandHSLN/AWifeHSLN/A
Providing for and protecting a spouse.HusbandHSLN/AWifeHSLN/A
Providing for and protecting children.HusbandHSLN/AWifeHSLN/A
Providing for and protecting grandchildren.HusbandHSLN/AWifeHSLN/A
Disinheriting a family member.HusbandHSLN/AWifeHSLN/A
Providing for charities at the time of death.HusbandHSLN/AWifeHSLN/A
Plan for the transfer and survival of a family business.HusbandHSLN/AWifeHSLN/A
Avoiding or reducing your estate taxes.HusbandHSLN/AWifeHSLN/A
Avoiding probate.HusbandHSLN/AWifeHSLN/A
Reduce administration costs at time of your death.HusbandHSLN/AWifeHSLN/A
Avoiding a conservatorship (“living probate”) in case of a disability.HusbandHSLN/AWifeHSLN/A
Avoiding will contests or other disputes upon death.HusbandHSLN/AWifeHSLN/A
Protecting assets from lawsuits or creditors.HusbandHSLN/AWifeHSLN/A
Preserving the privacy of affairs in case of disability or at time of death from business competitors, predators, dishonest persons and curiosity seekers.HusbandHSLN/AWifeHSLN/A
Plan for a child with disabilities or special needs, such as medical or learning disabilities.HusbandHSLN/AWifeHSLN/A
Protecting children’s inheritance from the possibility of failed marriagesHusbandHSLN/AWifeHSLN/A
Protect children’s inheritance in the event of a surviving spouse’s remarriage.HusbandHSLN/AWifeHSLN/AProvide that your death shall not be unnecessarily prolonged by artificial means or measures.HusbandHSLN/AWifeHSLN/A
Other Concerns (Please list below):

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

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

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.

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

YesNoHave 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.

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

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

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

YesNo

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

YesNoIf 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

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

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

YesNoDo any of your children receive governmental support or benefits?

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

YesNo
Additional 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:

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

General Description and/or Address

Owner

Market Value

Loan Balance

Total

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.).

Type or Description

Owner

Market Value

Total

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

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

Name of Institution and account number

Type

Owner

Amount

Total

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.

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)

Stocks, Bonds or Investment Accounts

Type

Acct. Number

Owner

Amount

Total

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.

Total

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.

Total

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.

Total

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

Name of Debtor

Date of Note

Maturity Date

Owed to

Current Balance

Total

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.

Description

Total estimated value

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

Type

Owner

Value

Total

Amount

Assets

Real Property

Furniture and Personal Effects

Automobiles, Boats and RV’s

Bank and Savings Accounts

Stocks and Bonds

Life Insurance and Annuities

Retirement Plans

Business Interests

Money owed to you

Anticipated Inheritance, Etc.

Other Assets

Total Assets:

Note: Joint Property values enter 1/2 in husband’s column and 1/2 in wife’s column.

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.

Name and Address

Relationship

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.

Name and Address

Relationship

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

Name and Address

Relationship

For Wife

Name and Address

Relationship

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

Name and Address

Relationship

For Wife

Name and Address

Relationship

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?

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

For Husband:

Spouse, then children equally Spouse, then to balance of trust. Spouse, then other named individuals. Children To the balance of the trust.
Other named individuals. List on next line.

For Wife:

Spouse, then children equally Spouse, then to balance of trust. Spouse, then other named individuals. Children To the balance of the trust. Other named individuals. List on next line.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:

Individual or Charity

Amount or Property

Contingent on Wife predeceasing?

For Wife:

Individual or Charity

Amount or Property

Contingent on Wife predeceasing?

Everything to surviving spouse Divide to the following individuals in accordance with the following percentages or terms:

Divide equally between our children and the descendants of any deceased children: Divide among named individuals and/or charities: Division of property upon death of second spouse to die

How and when to distribute my property:

Distribute outright to our beneficiaries: Provides no protection from creditors, predators, or from themselves. STRUCTURED TRUST: You determine how long the property is to remain in trust. During the period of time the property is held in trust it is available to the beneficiary for needs (health, education and maintenance). You may give written instructions to the trustee outlining guidelines to follow in determining the beneficiary’s needs. You may provide for a staggered distribution of principal. For example:. 1/3 at age 30 and balance at age 40. You decide who will manage the property and to carry out your distribution instructions. Does the beneficiary have a right to be a cotrustee and/or choose his or her own cotrustee? You decide how the trust is designed. List your desires:

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:

To each spouse’s heirs-at-law. One half to Husband’s heirs-at-law and one half to Wife’s heirs-at-law. To the following named individuals and/or charities:

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

Name

Relationship

Address and Phone Number

Wife’s Agent

Name

Relationship

Address and Phone Number

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

Name

Relationship

Address and Phone Number

Wife’s Agent

Name

Relationship

Address and Phone Number

OTHER ITEMS TO INCLUDE OR DISCUSS: Obviously your estate plan should address all your hopes, fears, and wishes. Please list any other items you want included or want to discuss:

Brief description of your legal issue

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I have read the disclaimer.