Estate Planning Questionnaire

Name:

Birth date: U.S. Citizen:

Principal Residence:

Any other Domicile:

Domicile in community property states(s) (if ever):

Birthplace: Social Security Number:

Dates of such domicile:

Community property acquired:

Business or profession:

Still: Active Retired

Current marital status: Single Married Widowed Divorced

Prior Marriages (if any):

Name of former spouse(s):

Name and ages of children of prior marriages:

How and when prior marriage(s) ended:

Principal bank(s):

Personal Trust officer:

Location of safe deposit box(es):

Accountant:

Investment advisor:

Insurance advisor:

Name:

Date and place of birth: U.S. Citizen:

Social Security Number:

Date and place of marriage:

Legally separated:

When and where:

Residence (if different from estate owner’s):

Business or profession:

(Designate which children or grandchildren, if any, are adopted, are stepchildren or are children of a prior marriage)

Executor(s)

Name:

Address:

Successor(s)

Name:

Address:

Trustee(s)

Name:

Address:

Successor(s)

Name:

Address:

Children’s Guardian(s)

Name:

Address:

Successor(s)

Name:

Address:

(obtain copies of instruments of transfer and gift tax returns)

Donee:

Date of Gift:

Type of property given:

Date of gift value:

Outright or trust gift:

Was gift split with spouse? If yes, who paid gift tax?

A. REAL ESTATE (including condominium, apartment)

Description or Address:

Description or Address:

B. STOCKS AND BONDS

Name: Type of Business:

Address:

Name: Type of Business:

Address:

C. U.S. government bonds (e.g., Series “E” or “EE” bonds)

Payable on Death to: Face Value: Issue Date: Current Value:

D. CASH

Name & Address of Bank: Account Number:

Checking or Savings: Trust Account Beneficiary:

E. MORTGAGES AND PROMISSORY NOTES

Name of Mortgagor or Creditor: Unpaid Face Value: Repayment Balance: Interest Terms Rate:

F. LIFE INSURANCE

Company: Policy Number: Name of Insured:

Current Beneficiary: Date:

Face Amount of Policy: Death/Loan Value:

G. GENERAL POWERS OF APPOINTMENT

Instrument conferring Power created: Date power subject to power: Value of property:

H. ANNUITIES AND DEATH BENEFITS (Include Keogh plans and IRAs)

Annuity or Lump sum Type of Plan: Estate Designated Payment: Owner’s Beneficiary: Approx. Contribution: Value:

(To avoid confusion at a later date, describe each item as clearly as possible.)

Cash (on hand):

Cash (in banks/credit unions):

Other Cash:

Stocks/Bonds:

Other Stocks and Bonds:

Notes (money owed to you in writing):

Money owed to you (not evidenced by a note):

Real estate:

Business Interests:

Automobiles:

Boats:

Other vehicles:

Retirement plans (Profit Sharing, Pension, IRA, 401(k)s, etc.):

Furniture & furnishings in home:

Furniture & furnishings elsewhere:

Collectibles:

Jewelry:

Life insurance (cash surrender value):

Sporting and entertainment (T.V., stereo, etc.) equipment:

Other assets:

Total Assets:

Mortgages on real estate: (Home)

Charge/credit card accounts

Auto loan

Bank/credit union loans

Money you owe (not evidenced by a note)

Judgments

Other

Total Debts and Liabilities:

Summary of Assets and Liabilities

Total Assets:

Less Total Liabilities:

Net Worth:

Husband Accounts:

Wife Accounts:

Income of Husband (Monthly)

Salary:

Dividends:

Rental Income:

Notes Receivable:

Bonuses:

Business:

Other:

Total Income:

Income of Wife

Salary:

Dividends:

Rental Income:

Notes Receivable:

Business:

Bonuses:

Other:

Total Income:

(Who will receive your property)

Do you want all property to go to spouse, or if spouse not alive to your children? Yes

Who is to receive home?

Describe who you desire to receive other property.

Name of Person to Receive Property: Description of Property:

Name of Person to Receive Property: Description of Property:

Name of Person to Receive Property: Description of Property:

Describe any other last wishes

(For Additional Information)