ESTATE PLANNING QUESTIONNAIRE
Date Referred By:
Your Name (full name): U.S. Citizen: Yes No Citizenship:
Address:
Date of Birth: / /
Telephone No.: ( ) Cellular No.: ( ) Other No.: ( ) Fax No.: ( )
Email:
County of Residence:
Spouse/Partner’s Name (full name): U.S. Citizen: Yes No Citizenship:
Address:
Date of Birth: / /
Telephone No.: ( ) Cellular No.: ( ) Other No.: ( ) Fax No.: ( )
Email:
County of Residence:
FAMILY INFORMATION
Are you married or in a registered Domestic Partnership? Yes No CHILDREN(S):
NAME BIRTH DATE CHILD OF:
Deceased Children? Yes No
If yes, please provide name(s) and date(s) of death:
Prior marriages? Yes No
Marriage was terminated by Death Dissolution of Marriage
Date of death of spouse Date of Dissolution Please provide full name of former spouse(s): Use extra sheet if more room needed.
Children of former marriage? Yes No
(Indicate if named above.)
NAME BIRTH DATE
ASSET INFORMATION
It is crucial you provide all asset information. This will allow Bolander Cook & Associates to (1) assess your estate tax liability and (2) advise you on how to hold title to assets. These asset pages will be discussed in depth at your initial Estate Planning meeting. Please indicate your current net worth, broken down as follows:
REAL PROPERTY: Address:
Fair market value $ Mortgage: $ NET: $
Fair market value $ Mortgage: $ NET: $
Fair market value $ Mortgage: $ NET: $
Check box if you have additional real property and attach information.
Banking Institution(s): Type of Account Average Balance
Example: Wells Fargo Checking/Savings $1,500/$7500
Check box if additional banking information is attached
Investments & Institution Type of Account Value
(List all CDs, Stocks, Bonds, Mutual Funds, Securities, etc.)
Check box if additional investment information is attached
Retirement & Insurance Type of Account/Policy Value/Death Benefit
Check box if additional retirement/insurance information is attached
Business Interests: (LLCs, Sole Proprietorships, Corporations, Partnerships) Type of Entity:
Stock or Ownership Interest:
Partners, Members or Shareholder/Director(s)’ Names: Buy/Sell Agreement? Yes No
Number of Employees:
Do you have the following for your business entity?
ESOP (Employee Stock Ownership Plan) 401(k) Defined Benefit Pension Plan
Profit Sharing Business Succession Planning
Other Assets: (Tangible personal property of significant value, expected inheritance, promissory notes, mineral rights, etc.)
OTHER ADVISORS
As your Estate Planning advisors, is our obligation to, not only ensure your estate planning goals are achieved, but also to ensure your overall financial well-being is properly cared for. I would like to honor this responsibility by making sure you have the highest level of professional advisors in place to provide maximum progress to achieve your financial goals. It is also
important that, if you already have advisors that you would rate as exceptional, I am aware of who they are. Knowing one another, during your lifetime, can greatly minimize problems and unnecessary expenses after your death or incapacity. Accordingly, please take the time to provide us with this valuable information:
FINANCIAL ADVISOR:
Do you have a written financial plan?
□
Yes□
No Do you have a financial advisor?□
Yes□
NoIf so, what is his or her name?
Phone Number: ( )
Please rate your Financial Advisor:
1 2 3 4 5 6 7 8 9 10
Please circle the appropriate number with 10 indicating you are extremely satisfied with your planner and 1 indicating you are dissatisfied.
MORTGAGE ADVISOR: Your real estate is one of your largest assets, if not the largest. How you structure your debt and equity become a critical part of your financial plan. Do you have a relationship with a mortgage advisor?
□
Yes□
NoIf so, what is his or her name?
Phone Number: ( )
Do you meet with your mortgage planner annually to review your plan?
□
Yes□
No Please rate your Mortgage Advisor:1 2 3 4 5 6 7 8 9 10
Please circle the appropriate number with 10 indicating you are extremely satisfied with your planner and 1 indicating you are dissatisfied.
Would you like an introduction to a “10” in this area?
□
Yes□
NoLIFE & DISABILITY INSURANCE: Life and Disability insurance are a crucial part of your financial plan and your estate plan.
Do you have adequate Life and Disability Insurance to protect the ones you love and those who depend on you?
□
Yes□
NoDo you have a Life and Disability Insurance advisor?
□
Yes□
NoIf so, what is his or her name?
Phone Number: ( )
Do you meet with your Insurance advisor annually to review your plan?
□
Yes□
NoDo you have Health
□
Yes□
No and/or Long-Term Care Insurance□
Yes□
NoPlease rate your Life and Disability Insurance Advisor:
1 2 3 4 5 6 7 8 9 10
Please circle the appropriate number with 10 indicating you are extremely satisfied with your planner and 1 indicating you are dissatisfied.
Would you like an introduction to a “10” in this area?
□
Yes□
No DWELLING AND AUTOMOBILE INSURANCE:Are your assets adequately insured in the event of fire, earthquake, a lawsuit or major accident?
□
Yes□
NoDo you have a Dwelling and Auto Insurance advisor?
□
Yes□
NoIf so, what is his or her name?
Do you meet with your Insurance advisor annually to review your plan?
□
Yes□
No Please rate your Insurance Advisor:1 2 3 4 5 6 7 8 9 10
Please circle the appropriate number with 10 indicating you are extremely satisfied with your planner and 1 indicating you are dissatisfied.
Would you like an introduction to a “10” in this area?
□
Yes□
NoThank you for providing this information. It is extremely important that your professional advisors are aware of one another’s existence and the planning each of us is doing for you. We will discuss this in more detail during our meeting.
CLIENT ACKNOWLEDGMENT & AUTHORIZATION I/we have provided all information regarding our assets.
I/we hereby give our consent to be contacted by the professionals requested above, if applicable.
I/we have read the foregoing and fully understand the statements contained herein. Date:
Signature Signature
Printed Name Printed Name
Best phone number to call: ( )
