Fill and Sign the Planning Questionnaire PDF Form

- 1 - 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 - 2 - CHILDREN AND GRANDCHILDREN (Designate which children or grandchildren, if any, are adopted, are stepchildren or are children of a prior marriage) Name Birth date Relationship Domicile Name of Spouse WHO WILL BENEFIT UNDER WILL Name Address Age Status (e.g. child, friend, employee) ฀฀ ฀฀ ฀฀ ฀฀ ฀฀ ฀฀ ฀฀ 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 - 3 - GIFTS MADE DURING LIFE (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? FINANCIAL INFORMATION A. REAL ESTATE (including condominium, apartment) Date Cost Current Mortgages Net Current Date Purchased Improvements Value Description or Address: Description or Address: Description or Address: Description or Address: Description or Address: Description or Address: B. STOCKS AND BONDS Name Type of Business Date Acquired Original Cost # of Shares Current Market Value Address: Address: Address: Address: Address: C. U.S. government bonds (e.g., Series “E” or “EE” bonds) Payable on Death to Face Value Issue Date Current Value - 4 - FINANCIAL INFORMATION 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: Face Amount of Policy: Death/Loan Value: Face Amount of Policy: Death/Loan Value: Face Amount of Policy: Death/Loan Value: Face Amount of Policy: Death/Loan Value: G. GENERAL POWERS OF APPOINTMENT Instrument conferring Power created Date power subject to power Value of property - 5 - FINANCIAL INFORMATION H. ANNUITIES AND DEATH BENEFITS (Include Keogh plans and IRAs) (get copies of contracts, plans, etc.) Annuity or Lump sum Type of Plan Estate Designated Payment Owner’s Beneficiary Approx. Contribution Value ASSETS: DESCRIPTION OF ALL ASSETS (To avoid confusion at a later date, describe each item as clearly as possible.) Current Fair Market Value Cash (on hand) Cash (in banks/credit unions)(From List Above) Other Cash: Stocks/Bonds (From List Above) Other Stocks and Bonds Notes (money owed to you in writing) Money owed to you (not evidenced by a note) Real estate: (From List Above) (Other) Business Interests Automobiles Boats Other vehicles Retirement plans (Profit Sharing, Pension, IRA, 401(k)s, etc.) Furniture & furnishings in home Furniture & furnishings elsewhere - 6 - ASSETS: DESCRIPTION OF ALL ASSETS (To avoid confusion at a later date, describe each item as clearly as possible.) Current Fair Market Value Collectibles Jewelry Life insurance (cash surrender value) Sporting and entertainment (T.V., stereo, etc.) equipment Other assets Total Assets LIABILITIES (To avoid confusion at a later date, describe each item as clearly as possible. ) Monthly Payment Current Amount Owed Mortgages on real estate: (Home) (Other) Charge/credit card accounts Auto loan Auto loan Bank/credit union loans Money you owe (not evidenced by a note) Judgments Other - 7 - LIABILITIES (To avoid confusion at a later date, describe each item as clearly as possible. ) Monthly Payment Current Amount Owed Total Debts and Liabilities Summary of Assets and Liabilities Total Assets Less Total Liabilities Net Worth Retirement Accounts Account Number Current Fair Market Value Husband Accounts: Wife Accounts: Income of Husband (Monthly) Monthly Yearly Salary Dividends Rental Income Notes Receivable Bonuses Business Other Total Income Income of Wife Monthly Yearly Salary Dividends Rental Income Notes Receivable Business Bonuses Other Total Income - 8 - Worksheets (Who will receive your property) Do you want all property to go to spouse, or if spouse not alive to your children? Yes If no please continue. If yes, stop. Who is to receive home? Describe who you desire to receive other property. Name of Person to Receive Property Description of Property Describe any other last wishes - 9 - LEGAL DOCUMENTS Document State Where Executed Location of Original Date Executed Last Will and Testament Durable Power of Attorney Living Will/Health Care Proxy Living Trust 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 - 10 - 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 c lient? For client’s spouse If the client’s spouse is, or going to be, in a nursing home or A LF, 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 financia l affairs? First Choice: Name Address Phone Second Choice Name Address Phone If you were in the hospital and unable to make decisions for your self, with whom would you want your doctor to consult with about your care (that is, to be your health care advocate)? First Choice: Name Address Phone Second Choice Name Address Phone 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/mana ge 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 c hildren (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)