ESTATE PLANNING QUESTIONNAIRE

DATE:

PERSONAL INFORMATION

FULL NAME:_________________________________________________

SOCIAL SECURITY NUMBER:__________  BIRTH DATE:_______________

CITIZENSHIP:______________________ MARITAL STATUS: __________

HOME ADDRESS:______________________________________________

___________________________________________________________

COUNTY OF RESIDENCE: _______________________________________

HOME TELEPHONE:  _____________________

HOME FACSIMILE: ______________________

OTHER CONTACT#: ______________________

HOME E-MAIL: _____________________________________

OCCUPATION:  _________________________

EMPLOYER:  ___________________________

BUSINESS ADDRESS:  _________________________________

BUS TELEPHONE: ____________________________

BUS FACSIMILE: ____________________________

OTHER CONTACT#:  __________________________

BUSINESS E-MAIL: __________________________

Previously married?: ______     If so, please provide:

(a)        Name of former spouse:   _________________________

(b)        Date on which terminated: ________________________

(c)        Manner inwhich the marriage terminated:_________________

(d)        Descendant(s) of prior marriage: ________________________

(e)        Was there a premarital or postmarital agreement’?_____________

PLEASE PROVIDE A COPY OF ANY DIVORCE DECREE, PREMARITAL AGREEMENT OR POSTMARITAL AGREEMENT.

SPOUSE’S INFORMATION

FULL NAME:_______________________________________

SOCIAL SECURITY NUMBER:____________________  BIRTH DATE:______

CITIZENSHIP: ______________________  MARITAL STATUS:__________

HOME ADDRESS:   _____________________________________________

COUNTY OF RESIDENCE:__________________________

HOME TELEPHONE: _____________________________

HOME FACSIMILE:  _____________________________

OTHER CONTACT#: _____________________________

HOME E-MAIL: ________________________________

OCCUPATION:  ________________________________

EMPLOYER: __________________________________

BUSINESS ADDRESS:   _______________________________________

BUS TELEPHONE: ____________________________

BUS FACSIMILE:  ____________________________

OTHER CONTACT#:  __________________________

BUSINESS E-MAIL: ________________________________________

Previously married?:    ______________

If so, please provide:

(a)        Name of former spouse:  ________________________________

(b)        Date on which terminated: _____________________

(e)                Manner inwhich the marriage terminated:__________________

(f)                 Descendant(s) of prior marriage:________________________

(e)        Was there a premarital or postmarital agreement’?  _____________

PLEASE PROVIDE A COPY OF ANY DIVORCE DECREE, PREMARITAL AGREEMENT OR POSTMARITAL AGREEMENT.

FAMILY MEMBERS

Please list living parents, children and grandchildren or yourself and your spouse.  Please also list any other individuals who will be beneficiaries under your estate plans. and any other individuals whom you may consider naming as Executor, Trustee or Guardian.  Please indicate whether their relation is to yourself or your spouse, and for Grandchildren please indicate which child is the parent.

NAME                          RELATION               ADDRESS                                          BORN

__________            ________                ___________________            _______

__________            ________                ___________________            _______

__________            ________                ___________________            _______

__________            ________                ___________________            _______

__________            ________                ___________________            _______

__________            ________                ___________________            _______

__________            ________                ___________________            _______

__________            ________                ___________________            _______

__________            ________                ___________________            _______

__________            ________                ___________________            _______

__________            ________                ___________________            _______

__________            ________                ___________________            _______

Please indicate if any child, grandchild or other potential beneficiary is:

[  ]adopted

[  ]born out of wedlock

[  ]divorced or separated

[  ]physically or mentally handicapped

FINANCIAL INFORNIATION

NET WORTH FOR ESTATE PLANNING:

ASSET CLASSIFICATION

Is home:                             [  ]  House                  [  ]    Condominium         [  ]  Co-op

Is title in land trust?      [  ]   Yes            [  ]     No

Is vacation home:          [  ]  House                  [  ]     Condominium        [  ]  Co-op

Is title in land trust?      [  ]  Yes             [   ]     No

Is any real estate potentially subject to any environmental concerns of which you are aware?________________________________________________

Total death benefits listed on item 2 above, excluding accidental death benefits._____________________________________________________

Please describe any loans between family members.____________________

____________________________________________________________

Assets, including death benefit from life insurance policies, minus liabilities.

___________________________________________________________

1. Community Property

Have you ever lived in a community property state during-, your marriage (Arizona, California, Idaho, Louisiana.  Nevada, New Mexico, Texas, Washington or Wisconsin)? _____ If so please indicate which one(s) and the dates on which you lived there:__________________________________

__________________________________________________________

PLEASE IDENTIFY COMMUNITY PROPERTY SHOWN ABOVE BY PLACING A “C” TO THE RIGHT OF THE APPROPRIATE ENTRY.

2.         Life Insurance Policies

3.         Joint Property

If any of the property shown above is owned jointly with someone other than your spouse, please indicate the co-owner(s), their respective interests in the property, and who provided the funds to purchase the property.  If any of the liabilities shown above are joint liabilities with someone other than your spouse, please indicate the co-obligor(s) and the nature of their respective liabilities.

___________________________________________________________

___________________________________________________________

___________________________________________________________

4.         Business Interests

List and briefly describe closely held business interests.  Please Indicate the type of’ entity and your interest in the entity.

___________________________________________________________

___________________________________________________________

___________________________________________________________

PLEASE PROVIDE COPIES OF ANY PARTNERSHIP AGREEMENT, SHAREHOLDERS’ AGREEMENT, BUY-SELL AGREEMENT, VOTING TRUST, OR OTHER SIMILAR AGREEMENT.

5.         Employee Benefits

Describe any pension or profit-sharing plans applicable to yourself or your spouse.  Give the name of the plan; general description of the benefits; the name of the beneficiary; and indicate whether you made any contributions to the plan.

___________________________________________________________

___________________________________________________________

___________________________________________________________

Describe any stock options, deferred compensation and other employee benefits.

___________________________________________________________

___________________________________________________________

___________________________________________________________

PLEASE PROVIDE THE SUMMARY PLAN DESCRIPTION AND LATEST STATEMENT OF BENEFITS PROVIDED BY YOUR RESPECTIVE EMPLOYERS.

6.         Individual Retirement Accounts

7.         Tangible Personal Property

Please describe any tangible personal property requiring special treatment (for example, art objects, collections, boats, horses or antiques).

___________________________________________________________

___________________________________________________________

8.         Trusts

Please describe any trust you or your spouse has established, including, the value of the trust assets. Did the trust become irrevocable on or before_____________ , ? If so, were additional contributions made to it after _______________ ______, ________ ?

___________________________________________________________

___________________________________________________________

Please describe any interest that you or any family members have in any trust created by another,_________________________including the value of the trust assets. Did the trust become irrevocable on or before_________ ________, ______ ? If so, were additional contributions made to it after__________  ____ ,  _______?

PLEASE PROVIDE COPIES OF ANY SUCH TRUST INSTRUMENTS.

9.         Children’s Assets

Please describe any property held for your children, such as under a Uniform Transfers to Minors Act.

___________________________________________________________

___________________________________________________________

10.       Inheritances

Please describe any property you or your spouse has inherited within the past 10 years.

___________________________________________________________

___________________________________________________________

Please describe any inheritance that you or any member of your family expects to receive in the future.

___________________________________________________________

___________________________________________________________

ADDITIONAL INFORMATION

1.         Gifts

Have you ever filed a gift tax return?                  [  ]    Yes       [  ]      No

Has your spouse ever filed a gift tax return?    [  ]     Yes       [  ]      No

Please describe any gifts you or your spouse has made to any person (other than to each other and other than any gifts fully disclosed on a gift-tax return).

PLEASE PROVIDE A COPY OF ALL GIFT TAX RETURNS YOU OR YOUR SPOUSE HAS FILED.

2.         Current Estate Planning Documents

______________________________________________________________________________

PLEASE PROVIDE COPIES OF YOUR CURRENT ESTATE PLANNING DOCUMENTS.

3.         Family Advisors

4.         Safe deposit box

Where is your safe deposit box and who has access to it?

___________________________________________________________

___________________________________________________________

Attorney Specific Forms

–For Attorney Specific Forms you can download in Word format, go to

http://www.uslegalforms.com/forattorneys/