Estate Questionnaire

Estate Planning Questionnaire

DATE:

PERSONAL INFORMATION

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: (if divorce, get copies of any agreements and decrees)

Principal bank(s)

Personal Trust officer

Location of safe deposit box(es)

Accountant

Investment advisor

Insurance advisor

SPOUSE

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

CHILDREN AND GRANDCHILDREN

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

WHO WILL BENEFIT UNDER WILL

FIDUCIARIES

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

GIFTS MADE DURING LIFE

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?

FINANCIAL INFORMATION

A. REAL ESTATE (including condominium, apartment)

B. STOCKS AND BONDS

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

D. CASH

E. MORTGAGES AND PROMISSORY NOTES

F. LIFE INSURANCE

G. GENERAL POWERS OF APPOINTMENT

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

ASSETS: DESCRIPTION OF ALL ASSETS

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

LIABILITIES

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

Summary of Assets and Liabilities

Total Assets

Less Total Liabilities

Net Worth

Retirement Accounts

Income of Husband (Monthly)

Income of Wife

Worksheets

(Who will receive your property)

Do you want all property to go to spouse, or if spouse not alive to your children? Yes No

Who is to receive home?

Describe who you desire to receive other property.

Describe any other last wishes

LEGAL DOCUMENTS

Who are the Trustees of your trust?

Is your trust fully funded? Yes No

Are the assets properly allocated between the trusts? Yes No

Does your trust specify a test to determine your disability? Yes No

Does your trust address your spouse’s remarriage? Yes No

Does your trust contain Estate Tax planning? Yes No

Have the beneficiaries been changed on your retirement assets? Yes No

Is there a method to remove a trustee if necessary? Yes No

Do you own any joint tenancy property? Yes No

Does your trust contain in-home health care language? Yes No

Have the beneficiaries been changed on your life insurance? Yes No

Are family members successor trustees? Yes No

Does your trust give instruction on your care and the care of your loved ones during your disability? Yes No

Does your trust provide creditor protection for assets passing to your surviving spouse? Yes No

Does your trust address income tax planning? Yes No

Does your trust allow for continued gifting during your disability? Yes No

Does your trust protect your children’s inheritance from a divorcing spouse? Yes No

Does your trust provide creditor protection for your children’s inheritance? Yes No

NURSING HOME / ASSISTED LIVING

What is the private pay rate of the nursing home or assisted living facility (ALF) where the client or client’s spouse is staying or will be staying? Daily Monthly

List any other expenses that are anticipated at the nursing home or ALF

What is the monthly cost of Medicare Supplement Insurance for client?

For client’s spouse

If the client’s spouse is, or going to be, in a nursing home or ALF, how much income will be needed monthly to pay ongoing expenses of the well spouse?

LEGAL AND FINANCIAL DECISIONS

If you were unable to carry out your legal and financial business, who would you want to take care of your legal, business, personal, and financial affairs?

If you were in the hospital and unable to make decisions for yourself, with whom would you want your doctor to consult with about your care (that is, to be your health care advocate)?

Does any potential beneficiary have special educational, medical or physical needs, or receive governmental benefits? Yes No

Does any potential beneficiary have any potential problems with drug or alcohol abuse? Yes No

Are you concerned with any potential beneficiary’s ability to handle/manage money? Yes No

Are you concerned with your children’s ability to get along with one another? Yes No

Are their problems/concerns relative to your relationship with your children (or spouse’s children)? Yes No

Have any of your children received a divorce? Yes No

Do you expect to inherit money? Yes No If yes, describe:

Addendum

(For Additional Information)