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ESTATE PLANNING QUESTIONNAIRE

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PART I – PERSONAL AND FAMILY INFORMATION

  1. Full legal name  __________________________________________________________

  2. Address  _______________________________________________________________

  3. City, State and Zip Code  __________________________________________________

  4. County of residence  ______________________________________________________

  5. Telephone: Home  _______________________ Work  ___________________________

  6. Place of employment  ______________________________________________________

  7. Person who knows your whereabouts most of the time, other than a spouse:

    8. Name  _______________________________  Telephone _________________________

  8. Marital status:   Married  ______  Single  ______  Divorced  ______  Widowed  ______

  9. Have you been married before?  Yes  ______   No  ________

  10. Date of birth  _____________________________________

  11. Social Security No.  ________________________________

  12. Are you a United States citizen?  Yes  ______  No  ________

  13. Full legal name of spouse  ___________________________________________________

  14. Spouse’s date of birth  ______________________________

  15. Spouse’s Social Security No.  _________________________

  16. Spouse’s place of employment  _______________________________________________

  17. Is your spouse a United States citizen?  Yes _____  No ______

  18. *Children from current marriage:

Name                                Birth Date     Marital Status  Address, if different from yours          
____________________  _________  __________  _____________________________
____________________  _________  __________  _____________________________
____________________  _________  __________  _____________________________
____________________  _________  __________  _____________________________
____________________  _________  __________  _____________________________
      *Please list all of your children’s names, even if you plan to leave them out of your Will.

  1. *Children from a previous marriage:

Name                                Birth Date     Marital Status  Address, if different from yours          
____________________  _________  __________  _____________________________
____________________  _________  __________  _____________________________
____________________  _________  __________  _____________________________
____________________  _________  __________  _____________________________
____________________  _________  __________  _____________________________
____________________  _________  __________  _____________________________
      *Please list all of your children’s names, even if you plan to leave them out of your Will.

  1. *Children from a current or previous relationship:
    Name                                Birth Date     Marital Status  Address, if different from yours          
    ____________________  _________  __________  _____________________________
    ____________________  _________  __________  _____________________________

    2. *Please list all of your children’s names, even if you plan to leave them out of your Will.

  2. Are you planning on having more children?  Yes  _____  No  _____  Possibly  _____

  3. Are any of your children adopted?  Yes  _____  No  _____

  4. Are any of your children deceased?  Yes  _____  No  _____

  5. Were any of your children born to you when you were unwed, or were any of your
    grandchildren born to any of your children when they were unwed?  Yes  _____  No  ______
    Please explain:  ___________________________________________________________
    _______________________________________________________________________

  6. Do any of your children or others dependent on you have special needs due to mental or
    physical disabilities?  Yes  _____  No  _____  Please explain:  _______________________
    _______________________________________________________________________
    _______________________________________________________________________

  7. Are you supporting any persons other than your spouse or children
    (such as parents, brothers or sisters, etc.)?  Yes  _____  No  _____  Please explain:  ______
    _______________________________________________________________________
    _______________________________________________________________________

PART II – FINANCIAL INFORMATION

  1. Real Estate:

  1. If you own your own home, list the following:

    2. Address  ___________________________________________________________

    Do you own it with anyone else? (If you do, please state who):___________________

    __________________________________________________________________

    Your opinion of the home’s value  ________________________________________

    Approx. balance of mortgage / contract for deed  ____________________________

  2. If you own any other real estate, such as a farm, cabin, or rental unit, list the following:

Address or location  __________________________________________________

Do you own it with anyone else? (If you do, please state who):  __________________

__________________________________________________________________

Your opinion of the home’s value  ________________________________________

Approx. balance of mortgage / contract for deed  ____________________________

Type of property (cabin, rental, farm, etc.)  _________________________________

*If you own more real estate, please use the back of this page and provide the same information.

  1. Please list below all bank accounts, certificates of deposit, money market certificates,
    IRA accounts, stocks, bonds or similar assets owned either in your name alone or jointly.
    (This information is needed in order to determine whether a basic Will is appropriate for your
    situation.  The information you provide is held in strict confidence. It will be discussed with you
    during your appointment. The Questionnaire will then be kept in your personal file.
    No one else will see this Questionnaire).

Bank or Co.  Type of Asset       In Whose Name        Beneficiary             Approximate Value
_________   _____________  ________________  ______________  ______________
_________   _____________  ________________  ______________  ______________
_________   _____________  ________________  ______________  ______________
*If more space is needed, please use the back of this sheet or on a separate sheet of paper.

  1. Life Insurance (on your life):
    Name of Ins. Co                                 Beneficiary                                        Amount of Policy
    ____________________________  ____________________________  _____________
    ____________________________  ____________________________  _____________
    ____________________________  ____________________________  _____________
    ____________________________  ____________________________  _____________

  1. Do you own or have an interest in any businesses? If so, describe briefly and give the
    approximate value of your interest:  ____________________________________________
    _______________________________________________________________________
    _______________________________________________________________________

  2. If you are covered by a pension or profit sharing plan, please state the name(s) of any
    beneficiary(s) under the plan, and its approximate value, if known:______________________
    _______________________________________________________________________
    _______________________________________________________________________

  3. Describe briefly, and give the approx. value, of any other valuable assets which you own
    (jewelry, antiques, guitars, stamp or coin collections, boats, automobiles, money owed to
     you by others, etc.):  ______________________________________________________
    _______________________________________________________________________
    _______________________________________________________________________

  4. Do you have child support or alimony obligations from a previous marriage? Yes ___ No____

  5. List any major liabilities or debts, aside from mortgages / contracts for deed: 
    Creditor                                                                                      Approximate Amount Owed
    _________________________________________________  _____________________
    _________________________________________________  _____________________
    _________________________________________________  _____________________

  1. Do you expect your financial situation to change substantially in the next five years?
    Yes  ____  No  ____  Please explain  __________________________________________
    _______________________________________________________________________

  2. Are you the beneficiary of any trusts?  Yes  ____  No  ____  Please explain  _____________
    _______________________________________________________________________

  3. Have you given anyone besides your spouse any gifts worth more than $10,000
    in any calendar year?  Yes  _____  No  _____

  4. Have you formally contracted to leave any assets to any person or organization?
    Yes  _____   No  _____

  5. Have you signed any pre-marriage contract regarding disposition of your assets?
    Yes  _____  No  _____  (If yes, please bring a copy of the agreement to your appointment.)

  6. Do you currently have a Will?  Yes  _____  No  _____
    (If yes, please bring a copy of your current Will to your appointment.)

  7. If you have a safe deposit box, please indicate the renters of the box and the location of the box:
    ________________________________________________________________________


PART III – GENERAL GOALS AND WISHES FOR YOUR WILL

  1. Whom do you wish to name as your PERSONAL REPRESENTATIVE executor?

    2. Most married persons name their spouse.

    1st Choice:  Name and relationship to you  ______________________________________
                       Address  ______________________________________________________
    2nd Choice: Name and relationship to you  ______________________________________
                       Address  ______________________________________________________

  2. If you are SINGLE AND HAVE CHILDREN, our basic Will leaves your estate in equal
    shares to your children. If one of your children should predecease you, do you want that child’s
    share of your estate to:

  1. Be split up among your remaining children  _____

  2. Pass to your deceased child’s children  _____

If you selected (b), please indicate grandchildren, if any:
Name                                       Date of Birth           Parents                                         
 _______________________  ______________  ___________________________
_______________________  ______________  ___________________________
If you want to leave your estate to persons other than your children, or only to particular
children, please indicate name(s), relationship to you, and address(es) below:
___________________________________________________________________
___________________________________________________________________

  1. If you are SINGLE, WITHOUT CHILDREN, whom would you want to receive your estate?
    First Choice  (you can choose one or more persons to share in your estate):
    Name(s), Relationship to you, and Address(es)  ___________________________________
    ________________________________________________________________________
    ________________________________________________________________________

    2. If one of the persons you named does not survive you, do you want such person’s share to go
    to his/her children, if he/she has any?  Yes _____  No _____
    If you would like to name a second choice of person(s) to receive your estate, please indicate:
    Name(s), Relationship to you, and Address(es)  ___________________________________
    ________________________________________________________________________
    ________________________________________________________________________

  2. If you are MARRIED AND HAVE CHILDREN, our basic Will leaves your estate to your
    spouse. If your spouse does not survive you, our basic Will leaves your estate in equal shares to
    your children. If your spouse does not survive you and if one of your children predecease you,
    do you want that child’s share of your estate to:
    a:  Be split among your remaining living children _____
    b:  Pass to your deceased child’s children _____
    If you selected (b), please indicate grandchildren, if any:
    Name                                                 Date of Birth   Parents                                                  
     ____________________________  ___________  ______________________________
    ____________________________  ___________  ______________________________
    ____________________________  ___________  ______________________________
    *If your children all still live with you, or you travel with your entire family, you may want to
    indicate whom you would like to receive your estate if something happens to your entire family.
    Most married couples choose to divide their estate in half, and leave half to each spouse’s
    relatives (either parents, brothers and sisters, or nieces and nephews), but you may also choose
    to leave the estate to one or more charities. Please indicate below the proposed distribution of
    your estate (including name(s), relationship to you, and address(es) of the intended beneficiaries):
    ________________________________________________________________________
    ________________________________________________________________________
    *If you need more space, please continue on a separate sheet of paper.

  1. If you are MARRIED, BUT HAVE NO CHILDREN, our basic Will leaves your estate to your
    spouse. Who would you want to receive your estate if your spouse does not survive you?
    Name(s), Relationship to you, and Address(es) – (you can choose one or more persons to
    share in your estate):  _______________________________________________________
    ________________________________________________________________________
    If one of the persons you named does not survive you, do you want such person’s share to go
    to his / her children, if he / she has any?  Yes ____  No ____

  1. Our basic Will allows you to nominate a GUARDIAN who will be responsible for your
    children and their estates until they reach the age of eighteen. Whom would you want to be the
    guardian of your minor children if your spouse does not survive you?
    Names, Relationship to you, and Address(es)  ____________________________________
    _______________________________________________________________________

  2. Our basic Will also allows you to extend the age under which your children’s estates are
    managed until the age of twenty-one, under the Uniform Transfers to Minors Act. If you would
    prefer to have your children’s estates managed until that age, indicate the name, relationship to
    you, and address of one individual whom you would like to act as custodian of your children’s
    estates: (Note: This person may be the same person you named in your answer to #6.)
    _______________________________________________________________________
    _______________________________________________________________________

  3. If you would prefer to have your children’s estates managed beyond both the age of eighteen
    and twenty-one, you may want to set up a trust. A trust involves additional planning and drafting,
    as well as additional costs, but it allows more flexibility and control in planning the ages at which
    your children will receive distributions from your estate. If you are interested in hearing about a
    trust, please inquire with our attorney drafting your Will.

  4. Our basic Will allows you to make specific dollar bequests if you so wish (this is optional):
    Gift                                Name, Relationship to you, and Address of the Recipient                   
    _______________ to ______________________________________________________
    _______________ to ______________________________________________________
    _______________ to ______________________________________________________
    _______________ to ______________________________________________________
    _______________ to ______________________________________________________

  5. If you are married, would you want the specific bequests you named in your answer to #9 to go
    to the recipients named, even if your spouse survives you?  Yes _____  No _____

  6. In addition, our basic Will makes reference to a list of tangible personal property items. Our
    attorney will distribute a blank list to you, which you may fill out at home, since this list does not
    need to be witnessed. If you have several personal belongings to distribute, and you would like
    us to prepare the list, please indicate the items below (this is optional):
    Gift                                Name, Relationship to you, and Address of the Recipient                   
    _______________ to ______________________________________________________
    _______________ to ______________________________________________________
    _______________ to ______________________________________________________
    _______________ to ______________________________________________________

  7. If you are married, would you want the items listed in your answer to #11 to go to the recipients
    named, even if your spouse survives you?  Yes _____  No _____

PART IV – MISCELLANEOUS

  1. Please give a brief statement of your intentions for your estate:  ________________________
    _______________________________________________________________________
    _______________________________________________________________________
    _______________________________________________________________________

  1. Please indicate below anything else you wish to discuss or questions you want answered:
    _______________________________________________________________________
    _______________________________________________________________________
    _______________________________________________________________________

  2. How did you hear about our firm?  ____________________________________________

I hereby certify that the information I have provided in this Estate Planning Questionnaire is complete
and accurate to the best of my knowledge. I hereby acknowledge that if I have not provided full and
accurate disclosure of information in this Questionnaire, it may be detrimental to my attorney’s ability
to effectively prepare estate planning on my behalf.

_______________________________                  ____________________________________
                      Date                                                                     Client's Name

 

There are two very important documents which you should consider in your Estate Planning. There is an extra charge for these documents.

Financial Power of Attorney    -     Health Care Directive

 

FINANCIAL POWER OF ATTORNEY
A Power of Attorney form is a written authorization for a person to handle property or financial matters for another individual. 

The person signing the Power of Attorney form and giving someone power over his or her assets is called the "principal." The person named to handle the principal's assets is called the "attorney-in-fact." 

You can name one or more persons to act as your attorney(s)-in-fact. You can require the attorneys-in-fact to act jointly, meaning that they must agree on all decisions and both sign all documents related to your financial affairs. In the alternative, you can allow either attorney-in-fact to act at any time. In addition, you can name a successor attorney-in-fact to take over, should the attorney-in-fact you name, die, become incapacitated, resign, or otherwise be unwilling or unable to serve as your attorney-in-fact.

You can designate an expiration date for the powers on the form. If there is no expiration date stated, the form will continue to be in effect until your death, or until you revoke the form. The Power of Attorney form can be revoked at any time, while you are competent, by a notarized written revocation form. A copy of this written revocation form should then be given to your attorney-in-fact, and to any third party who might be relying on the form. In addition, you must designate on the form whether you want the powers given to the attorney-in-fact to continue even if you become incapacitated or incompetent. This makes the form a "Durable" Power of Attorney.

The Power of Attorney form indicates a series of powers you can give to the attorney-in-fact, including power over real estate, personal property items, stocks, bonds, bank accounts, business transactions, and any insurance matters. You can choose to give the attorney-in-fact power over all of these matters, or just restrict the power to certain matters.

The form takes effect the date you sign it, however, while you are still competent, you have the right to control your own property and assets. To provide safeguards, you can indicate on the form that the attorney-in-fact is required to give periodic accountings to you, or to another interested party. 
You should be sure the person or persons you choose to be your attorney(s)-in-fact are trustworthy, and willing and able to handle the responsibility of managing your financial affairs, should you become incapacitated.

If you want us to prepare a Financial Power of Attorney, please complete the following:

 

Attorney-in-Fact 
(If you are married, most people name their spouse):

Successor Attorney-in-Fact

Name:

_______________________________


Name:

_______________________________


Address:

_______________________________

_______________________________


Address:

_______________________________

_______________________________


Relationship:

_______________________________


Relationship:

_______________________________

    Can the person named as your Attorney-in-Fact transfer assets to themselves?  YES  NO


HEATH CARE DIRECTIVE

(ALSO KNOWN AS HEALTH CARE POWER OF ATTORNEY)

 

The law authorizing the use of the Health Care Directive became effective August 1, 1998.  It allows competent adults to appoint someone, called an agent, to make health care treatment decisions for them when they are unable or unwilling to communicate a decision for themselves.  It allows the written expressions of preference and instructions to the agent, which the agent must follow.  It helps your family and your doctor.  It lets them know the kind of health care treatment you want or don't want if you can't speak for yourself. 

The law permits but does not require you to name an alternative agent.  However, it is a good idea to name an alternative agent since your primary agent may be out of town or ill when needed to make decisions for you. 

 Any competent person 18 years of age or older can execute a Health Care Directive.  Health Care Directives are not only for older persons; they are for people of all ages.  If your 18 year-old child was injured, it would enable you to participate in the health care decisions.

 The Health Care Directive replaces the living will and allows you to express your wishes concerning life support by artificial means, organ donation and disposition of your body at death.

Please complete the following if you would like us to prepare a Health Care Directive for you:

 

Agent  
(If you are married, most people name their spouse):

Alternative agent


Name:

_______________________________


Name:

_______________________________


Address:

_______________________________

_______________________________


Address:

_______________________________

_______________________________


Relationship:

_______________________________


Relationship:

_______________________________


Phone:

_______________________________


Phone:

_______________________________

I wish to donate my organs, tissue and other body parts when I die.  YES   NO 

I have agreed in another document or on another form to donate my organs when I die.  YES   NO 

I request cremation of my remains.   YES   NO