Confidential Estate Planning Questionnaire

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Confidential

Estate Planning Questionnaire

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This questionnaire is designed to help me evaluate your unique situation and create an estate plan that addresses your specific needs. Effective estate planning requires detailed

knowledge concerning your family and financial circumstances. The more information I have regarding your personal, family and financial situation, the better I can advise you and guide you through the estate planning process. Therefore, this questionnaire should be filled out as com- pletely as possible. Please feel free to approximate the value of your assets to the nearest $1000, but be very careful in correctly noting the identity of your assets and exactly how each asset is owned. Whether an asset is owned individually, jointly, in trust, or has a beneficiary designation can dramatically impact your estate plan. My goal is to create a plan suited to your individual needs, that puts your mind at ease by providing you with the knowledge that your affairs are in good order.

In addition to providing me with family and financial information, there are various issues that you should give some thought to during the estate planning process. For example, if you have minor children, who will you name as their guardian(s) should something happen to you? In the event of your death, who would be best suited to serve as executor of your estate? Finally, if a trust is appropriate for your situation, who should serve as trustee, a financial institution, a family member or a friend? These types of decisions require a great deal of thought and it is important to consider a person’s ability to serve in these capacities, as well as their time and inclination to do so.

Finally, I generally recommend that in addition to having a Will or Trust as the cornerstone of your estate plan that you also consider executing a Durable Power of Attorney for Property and a Power of Attorney for Health Care. The first document allows you to name an agent and successor agents to make financial decisions for you in the event that you become incapacitated and can- not make decisions for yourself. A Power of Attorney for Health Care is a similar but unique tool designed to govern who will make health care decisions for you, in the event that you are unable to make decisions for yourself. This document is widely recognized and accepted by hospitals and medical institutions, and allows you to name an agent and select one of three parameters to guide your agent. In addition to a Power of Attorney for Health Care, I also advise all clients to consider executing a Living Will, which is designed to set forth your wishes regarding your end of life health care choices.

Signature: ______________________________________________________________________________

Single Person

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ABOUT YOU:

Previously married? Yes No

Reason for termination? Death Divorce

If previously married, is there a dissolution property settlement in effect? Yes No

CHILDREN (if any):

Name (include former names) Name & Address

Telephone Number Email Address

Birth Date

Social Security Number

Occupation

Citizenship

Full Name Birth Date Social Security Number

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GUARDIANSHIP OF MINOR CHILDREN:

If any of your children are minors, who would you like to be their guardian(s)?

Guardian(s): _____________________________ Relationship: ___________________

Successor guardian(s): ______________________ Relationship ____________________

GRANDCHILDREN (if any): (use back side of sheet for more space)

PREVIOUS ESTATE PLANNING:

Do you have current wills or trusts in effect? ______________________________

If so, please give the date of execution and location of each document & provide a copy:

Will _______________ Trust _________________________

PRESENT ESTATE PLANNING:

Who would you like to serve as Executor and Successor Executor of your estate?

Full Name Birth Date Parents’ Names

Executor: ________________________________

Address:_________________________________

City:________________State:_____ Zip:_______

Phone #: _________________________________

Successor Executor: _______________________

Address:_________________________________

City:________________State:_____ Zip:_______

Phone #: _________________________________

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Who would you like to name as agent of your power of attorney for property?

Who would you like to name as agent of your power of attorney for healthcare?

EXPECTED INHERITANCES:

Do you expect an inheritance?

From whom? __________________________________ Value: ____________

Agent: ___________________________________

Address:_________________________________

City:________________State:_____ Zip:_______

Phone #: _________________________________

Successor Agent: __________________________

Address:_________________________________

City:________________State:_____ Zip:_______

Phone #: _________________________________

Agent: __________________________________

Address:_________________________________

City:________________State:_____ Zip:_______

Phone #: _________________________________

Successor Agent : _________________________

Address:_________________________________

City:________________State:_____ Zip:_______

Phone #: _________________________________

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PROFESSIONAL ADVISORS:

Name of Financial Planner/Broker: __________________________________________________

Name of Accountant: ____________________________________________________________

Name of Life Insurance Agent(s): __________________________________________________

Do you have a long-term care (nursing home) insurance policy? __________________________

BANK ACCOUNTS:

Location of safety deposit box:

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REAL ESTATE:

Name of Institution Type of Account (savings, checking, money market, CD)

Registration of Account (sole, joint, trust)

Average Balance

TOTAL:

Type of Real Estate

(residence, farm, etc.)

Real Estate Address or Location

Legal Title (sole, joint, trust)

Fair Market Value

Mortgage(s) Balance due

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SECURITIES:

BROKERAGE ACCOUNTS AND MUTUAL FUNDS (use back of this sheet for additional entries)

INDIVIDUALLY HELD STOCKS AND BONDS (use back of this sheet for additional entries)

BUSINESS INTERESTS:

PARTNERSHIP, JOINT VENTURE, CLOSELY HELD CORPORATION, PROPRIETORSHIP (use back of this sheet for additional entries)

Institution or Firm Type of Account Account Registration (sole, joint, trust)

Value

Name of Company or Bond Account Registration (sole, joint, trust)

Number of Shares

Value

Type of Interest Ownership % of Ownership or Number of Shares

Value

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RETIREMENT PLANS:

IRA, KEOGH, PENSION PLAN, 401(k), PROFIT SHARING PLAN (use back of this sheet for additional entries)

LIFE INSURANCE:

OTHER MISCELLANEOUS ASSETS: Below, please list any other assets, such as automobiles, boats, trailers, campers, mobile homes, savings bonds, extremely valuable collections, and any other valuable assets not listed elsewhere.

Type of Plan Registration Value

Insurer Insured Owner Primary & Contingent

Beneficiaries Face Amount

Cash val- ue

(whole life)

Asset Ownership Value Comments

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LOANS AND NOTES: (Other than mortgages listed on page 5)

CHARITABLE BEQUESTS: Please list any charitable organizations you would like to include in your estate plan.

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SPECIFIC BEQUESTS: Please list any specific gifts you know you would like to include in your planning documents. (You may use the back side of this sheet for extra space.)

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SPECIAL FAMILY OR FINANCIAL CIRCUMSTANCES: If you have any special family or financial circumstances that should be taken into account in your estate planning, please note those items here.

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NOTICE: The use and/or submission of this form for communication with the firm or any member of the firm does not create an attorney-client relationship . Time-sensitive information should not be submitted through this form.

Financial Institution Debtor

(husband, wife, joint)

Date Due Balance

TOTAL: