Estate Planning Questionnaire - Individual

Confidential Estate Planning Questionnaire

This questionnaire is designed to help us gather the information necessary to properly plan to protect your assets (or the assets of a family member or friend) during a time when there may be a need for Long-Term Care. Whether you are new or an established client, we have found this questionnaire extremely helpful and we ask your indulgence in completing it fully. Those questions that do not apply to you, your family, or your financial situation may simply be ignored.

Date*

A. Personal Information

Name

Prefix First Middle Last Suffix

Prior Name(s)

Physical Home Address

Street Address Address Line 2 City State ZIP Code

Mailing Address (If different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Cell Phone

Date of Birth

MM

DD

YYYY

Place of Birth

B. Prior Marriage(s)

Former Spouse Name(s)

Example(s): 1. John Doe; 2. Bob Johnson

Marriage Date(s)

Example(s) 01/01/1990; 10/10/2010

Date Marriage(s) Terminated: By Divorce or By Death

Ex: Divorce: 01/01/1990

Obligations to or from former spouse:

Child Support:

C. Children

Child #1

First Last

Date of Birth (DOB)

MM

DD

YYYY

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Marital Status

Spouse's Name (if applicable)

First Last

Name(s) of the Children of Child #1 (if applicable)

Child #2

First Last

Date of Birth (DOB)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Marital Status

Name of Spouse (if applicable)

First Last

Name(s) of the Children of Child #2 (if applicable)

Child #3

First Last

Date of Birth (DOB)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Marital Status

Spouse's Name (if applicable)

First Last

Name(s) of the Children of Child #3 (if applicable)

Child #4

First Last

Date of Birth (DOB)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Marital Status

Name of Spouse (if applicable)

First Last

Name(s) of the Children of Child #4 (if applicable)

Deceased Children (Include date of death)

Survived by (Include whether they are survived by any children)

D. Other Dependents

Name

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

E. NAMES AND ADDRESSES OF PERSONS TO ADMINISTER YOUR ESTATE OR TO ACT AS YOUR AGENTS

1. Names and addresses of persons you wish to name as EXECUTOR and SUCCESSOR EXECUTOR of your will:

Please provide name and address of your EXECUTOR of your will:

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Please provide name and address of your SUCCESSOR EXCECUTOR:

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

2. Names and addresses of persons you wish that they administer your trust and act as trustees in the event of your incapacity or death (During your life you will act as your own trustee.)

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Names and addresses of GUARDIANS OF MINORS (For children under age 18).

First Choice:

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Second Choice:

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Third Choice:

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

4. Names and addresses of persons (other than your spouse) to act as your AGENT under a FINANCIAL POWER OF ATTORNEY. (Preferably the same persons as trustees of your trust to avoid conflicts.)

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

F. FINANCIAL INFORMATION

If you own your home, list the following:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How is the title to the property held?:

Joint Tenancy
Community Property

Your Opinion of the Home's Value:

Approximate Balance of Mortgage

Do you own any other real estate?

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How is he title to the property held?

Joint Tenancy
Community Property

Your opinion of the home's value

Approximate balance of the mortgage

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How is the title to the property held?

Joint Tenancy
Community Property

Your opinion of the property's value

Approximate balance of mortgage

Do you own any other real estate?

Yes
No

If yes, please list the address below.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How is the title to the property held?

Joint Tenancy
Community Property
Other

If other, please list below.

Your opinion of the home's value

Approximate balance of mortgage

In addition to the real estate listed above, do you own any other real estate?

Yes
No

If yes, please list the address below.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How is the title to the property held?

Joint Tenancy
Community Property
Other

If other, please list below.

Your opinion of the property's value

Approximate balance of mortgage

List

Bank/Institution	Account #	Type of Asset	Value

List

Brokerage Company	Account #	Type of Asset	Value

Company #1

Type of insurance

Amount & Cash Surrender Value

Insured

Primary Beneficiaries

Secondary Beneficiaries

Company #2

Type of insurance

Amount & Cash Surrender Value

Insured

Primary Beneficiaries (Name & DOB)

Secondary Beneficiaries (Name & DOB)

Company #3

Type of insurance

Amount & Cash Surrender Value

Insured

Primary Beneficiaries (Name & DOB)

Secondary Beneficiaries (Name & DOB)

Account Name & Full Account Number

Value

Primary Beneficiaries (Name & DOB)

Secondary Beneficiaries (Name & DOB)

Account Name & Full Account Number

Value

Primary Beneficiaries (Name & DOB)

Secondary Beneficiaries (Name & DOB)

Account Name & Full Account Number

Value

Primary Beneficiaries (Name & DOB)

Secondary Beneficiaries (Name & DOB)

Account Name & Full Account Number

Value

Primary Beneficiaries (Name & DOB)

Describe and give the approximate value of your interest:

Are you partners in a Family Limited Partnership?

Yes
No

If yes, please explain

Describe and give the approximate value of your interest (jewelry, art work, antiques, guitars, stamp or coin collections, boats automobiles, etc.)

Is money owed to you by others?

Yes
No

If yes, please provide names & amount owed

List

Creditor	Approximate Amount Owed

Are you the beneficiary of someone else's trusts?

Yes
No

If yes, please explain

Are you likely to receive any gifts or inheritances?

Yes
No

If yes, please explain

Do you intend to make regular gifts to any person?

Yes
No

If yes, please explain

Do you wish to name a charitable organization as a possible beneficiary of your trust?

Yes
No

If yes, please list charitable organization(s)

G. Assets Distribution

It is preferred to distribute all your assets through the trust. Sometimes, however, you may wish to dispose of certain items of personal nature by your will.

Do you wish to make any specific bequests in your will?

Yes
No

If yes, please list bequest(s):

Personal effects and tangible personal items will be distributed to the trust and held and administered by the trustee in accordance with the trust terms. You may wish to provide a schedule of items that go to a specific person.

Do you wish to create a list (Schedule of items) of your personal effects and tangible personal property to be distributed with the rest of your estate?

Yes
No

Beneficiaries (Please list name(s) and specify if you wish to make any specific allocations)

Do you wish to disinherit someone?

Yes
No

If yes, please list name(s)

Default Beneficiaries (They will inherit in case you children and without issue of your children then living.) This can be a charity or a person. Please provide name(s) and address(es) of the default beneficiaries:

a. Age of youngest child before distribution:

b. Age for distribution (Typically the child receives all income from the trust but distribution of the principal is contingent upon the child's age.)

(a) First distribution of the principal of the trust:

(b) Second distribution:

(c) Third distribution:

Other specific provisions of information to be included in Will or Trust, such as operation or provision for family business, etc.

H. Burial & End of Life Planning

The power of attorney for medical care gives the person you name as your agent the authority to make a wide range of medical decisions on your behalf. It also gives your agent access to your medical information and authority to fully participate with your treating physicians in deciding the care to be provided to you. Obviously, the person you designate to be your agent should be someone you trust with life and death decisions. Please be sure to discuss these decisions with your agent and with your doctor in detail.

Person #1

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Person #2

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Person #3

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Advance Health Care Directive and Power of Attorney for Health Care are important health care decision making documents. It appoints someone you name to make medical care decisions for you if you cannot make your own medical decisions. It applies to more situations than the living will, which addresses only continued life support if you have a terminal condition.

Option #1

I recognize that modern medical technology has made possible the artificial prolongation of my life beyond natural limits. I do not wish to artificially prolong the process of my dying if continued health care will not improve my prognosis for recovery and my death is likely to occur within several months, or if I require life support as the result of an irreversible condition, even if that life support might prolong my life for a sustained period. Therefore, I do not want efforts made to prolong my life and I do not want life-sustaining treatment to be provided or continued: (1) if I am in an irreversible coma or persistent vegetative state; or (2) if I am terminally ill and the use of life-sustaining procedures would serve only to artificially delay the moment of my death; or (3) under any other circumstances in which the burdens of treatment outweigh the expected benefits. BY an "irreversible coma," I mean a coma from which the treating physicians have reasonably concluded I will never regain consciousness. In making decisions about life-sustaining treatment under provision (3) above, I want my agent to consider the relief of suffering and quality of remaining life as well as the extent of the possible prolongation of my life. At the same time that I am signing this advance health care directive, I am entering entering my initials in the space immediately below this provision to show that I have read this provision and that it reflects my desires.

Please select the paragraph that best expresses your wishes. If you would like to add other language or remove language, please feel free to do so. I also have language that comports with most religions. If you would like to see something that is more in line with the Christian, Catholic, or Jewish father, please call me.

Enter initials here for Option #1

Option #2

I want to receive medical treatment that prolongs and sustains my life unless I am in an irreversible coma. By an "irreversible coma," I mean a coma from which the treating physician or physicians have reasonably concluded I will never regain consciousness. If I am in such an irreversible coma, I do not want to receive medical treatment that prolongs and sustains my life. At the same time that I am signing this advance health care directive, I am entering my initials below this provision to show that I have read this provision and that it reflects my desires.

Enter initials here for Option #2

Option #3

I want to live as long as possible; therefore, I want to receive all medical treatment that will prolong and sustain my life within the limits of generally accepted health care standards. I want such treatment provided to me regardless of my chances of recovery, my condition, or the cost of such treatment. At the same time that I am signing this advanced health care directive, I am entering my initials in the space immediately below this provision to show that I have read this provision and that it reflects my desires.

Enter initials here for Option #3

Relief from Pain and Palliative Care

I direct that treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death. I wish to receive any other forms of palliative care that may ease my suffering. (Initial below)

Please state other wishes you may have about likes/dislikes or preferences toward the end of life. For instance: use of antibiotics, intravenous fluids which sustain the body, etc.

I. Organ Donation and Burial

Body organs donation (Do you wish to specify that you desire to donate your body organs for transplant upon death?):

Yes
No

If yes, are you also willing to donate organs and tissue for Medical, Educational, or Scientific purposes?

Medical
Educational
Scientific

Funeral Arrangements - You may have a strong desire regarding funeral arrangements (for example, burial or cremation.)

To be cremated.
To have my whole body or specific part given for medical or scientific purposes. ***
To be buried at a specified grave site or location ***
I do not wish to express my desires concerning my remains at this moment and I leave this decision to those who survive me.
I do not wish to express my desires concerning my remains in my will and leave this decision to those who survive me.

*** Please specify purposes/location:

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Life is short, plan well.℠

Amrine Law - EP Questionnaire - Individual

A. Personal Information

B. Prior Marriage(s)

C. Children

D. Other Dependents

E. NAMES AND ADDRESSES OF PERSONS TO ADMINISTER YOUR ESTATE OR TO ACT AS YOUR AGENTS

F. FINANCIAL INFORMATION

G. Assets Distribution

H. Burial & End of Life Planning

I. Organ Donation and Burial

Estate Planning Questionnaire – Individual

Amrine Law - EP Questionnaire - Individual

A. Personal Information

B. Prior Marriage(s)

C. Children

D. Other Dependents

E. NAMES AND ADDRESSES OF PERSONS TO ADMINISTER YOUR ESTATE OR TO ACT AS YOUR AGENTS

F. FINANCIAL INFORMATION

G. Assets Distribution

H. Burial & End of Life Planning

I. Organ Donation and Burial