Estate Planning Questionnaire

Estate Planning Client Questionnaire
Personal Information
Full Name

First NameLast Name
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long have you resided at this residence?
U.S. Citizen?

YesNo
U.S. Resident?

YesNo
Country of Citizenship (if other than U.S.)
Email
example@example.com
Phone Number

Area CodePhone Number
Last 4 Digits of SS#
Occupation
Employer

Prior Marriage?

YesNo
Previous marriages ended by death (name of spouse and date of death)
Previous marriages ended by divorce (name of spouse, and date of divorce)

Do you presently have a Will?

YesNo
Living Trust

YesNo
If yes, you may upload a copy, here.

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Is probate avoidance one of your estate plan objectives?

YesNo
Have you ever filed a gift tax return?

YesNo
Do you wish to make any bequests or contributions to charitable organizations? If so, please provide details (e.g., name and location of organization (city/state).

Provide the following information as to those professionals (if applicable) who advise you.
Accountant:
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Title and Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Trust Officer and/or Banker:
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Title and Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Other:
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Title and Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Do you have a Safe Deposit Box?

YesNo
Location of Safe Deposit Box

Asset and Liability Information

COMMENT: Separate schedules may be prepared to detail each asset, e.g., cash may be broken down into savings accounts, checking accounts, certificates of deposit, money market certificates, and liquid asset accounts, accompanied by the respective banking institution or investment firm in which each is held. The amount of detail required will depend on the size and nature of each individual estate. Please contact our office for assistance.
Household Income

Please include all sources of income, including social security, disability and other government benefits.

	Source	Amount	Frequency	Other
Client 1
Client 1
Client 2
Client 2
Other

Cash Assets

Please list only those assets valued at over One Thousand Dollars ($1,000.00). Estimate current value to the best of your knowledge. Assets of each spouse should be included.

	Institution	Account Holder(s)	Type of Account	Average Balance
Cash Asset
Cash Asset
Cash Asset
Cash Asset
Cash Asset
Cash Asset

Tangible Personal Property/Collectibles

Include autos, household furnishings, personal belongings and collectibles (estimate collective value). Individual items valued at over One Thousand Dollars ($1,000.00) should be listed separately. For any collectibles, please indicate separately how property was acquired, latest appraisal and provide copy of any insurance coverage.

	Owner(s)	Description	Cost at Acquisition	Present Value
TPP
TPP
TPP
TPP
TPP
TPP
TPP

Intangible Personal Property

This type of property includes stocks, mutual funds, bonds, notes and mortgages receivable. Attach brokerage statements whenever possible and list only a summary of accounts where statements are provided.

	Owner(s)	Description	Cost at Acquisition	Present Value
IPP
IPP
IPP
IPP
IPP
IPP
IPP

Real Estate

	Owner(s)	Description/Location	Cost at Acquisition	Current Value
Property
Property
Property
Property
Property

Business Interest

	Owner(s)	Name of Co.	Form (corp, parentership, other)	Value at Acquisition	Values of Shares Owned
Business
Business
Business
Business
Business

Pension, Profit Sharing, Other Employee Benefits and Annuities

Indicate if any IRAs are "Roth IRAs".

	Owner(s)	Name of Co.	Type	Value of Death Benefits	Named Beneficiaries
Business
Business
Business
Business
Business

Trust Interests

Include trusts either created by you or under which you have an interest.

	Trustee or Beneficiary	Date Trust was Established	Name of Settlor/Grantor	Your Interest
TI
TI
TI
TI

Expectancies

An “expectancy” is typically an anticipated inheritance or anticipated distribution from a trust.

	Recipient	From Whom	Relationship to You	Type and Value
Exp
Exp
Exp

Miscellaneous Assets

List other assets that cannot be classified in another asset category.

	Owner(s)	Description	Cost at Acquisition	Present Value
Other
Other
Other
Other
Other

Liabilities

Home mortgages, other mortgages, and revolving credit lines are examples of liabilities.

	Liable Party	Type of Liability	Original Amount	Date of Loan	Interest Rate	Creditor Name	Current Balance	Term
Liability
Liability
Liability
Liability

Contingent Liabilities

Loan guarantees and lawsuits are examples of contingent liabilities.

	Liable Party	Type of Liability	Original Amount	Date of Loan	Interest Rate	Creditor Name	Current Balance	Term
CL
CL
CL

Taxable Gifts
Were any gifts made by (either or both of) you during your lifetime for which a federal gift tax return (IRS Form 709) should be filed (i.e., gifts made by a donor which were in excess of $3,000 per donee during any calendar year prior to 1982 and in excess of $10,000 per donee during any calendar year after 1981)?

YesNo
If so, please describe the nature and amounts of these gifts in chronological order.
Were federal gift tax returns filed for such gifts?

YesNo
If so, please attach copies of all of your federal gift tax returns filed with the Internal Revenue Service.

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Stock Options
Do you have any stock options from corporations that employed you or for which you served as an officer or director?

YesNo
If so, please describe the nature and amounts of these gifts in chronological order.
Were Internal Revenue Code Section 83 elections made with respect to any such options?

YesNo

Insurance Issues
Life Insurance

	Insured Party	Company	Policy	Owner	Principle & Contingent Beneficiaries	Cash Value	Face Value	Annual Premium
LI
LI
LI

Disability Insurance

	Insured Party	Company	Policy	Owner	Monthly or Other Benefits	Term of Payments
DI
DI

General Liability Umbrella Insurance

	Insured Party	Company	Policy	Owner	Coverage	Underlying Coverage
GLUI
GLUI

Long-Term Health Insurance

	Insured Party	Company	Policy	Owner	Coverage	Underlying Coverage
LTHI
LTHI

Your Estate Planning Concerns

Please rate the following as to how important they are to you:
Desire to get affairs in order and to create a comprehensive plan to manage affairs in case of death or disability.
Providing for and protecting a spouse.
Providing for and protecting children.
Providing for and protecting grandchildren.
Disinheriting any children or descendants.
Providing for charities at the time of death.
Plan for the transfer and survival of a family business. Avoiding or reducing your estate taxes.
Avoiding probate.
Reduce administration costs at time of your death.
Avoiding a guardianship (“living probate”) in case of disability.
Avoiding will contests or other disputes upon death. Protecting assets from lawsuits or creditors.
Preserving the privacy of affairs in case of disability or at time of death from business competitors, predators, dishonest persons, and curiosity seekers.
Plan for a child with disabilities or special needs, such as medical or learning disabilities.
Protecting children’s inheritance from the possibility of failed marriages.
Protect children’s inheritance in the event of a surviving spouse’s remarriage.
Provide that your death shall not be unnecessarily prolonged by artificial means or measures.

Other Concerns:
Please list any other concerns or additional information not addressed previously.
Upload any relevant files here:

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Optional:

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Acknowledgement

We rely on the information you furnish us in making recommendations for the formulation and/or revision of your estate plan. If the information supplied is either inaccurate or incomplete, our recommendations may be inappropriate, or worse, harmful. We therefore rely upon you to take the necessary time and diligence to place in our hands data that can be used by us with confidence in helping you meet your objectives. We cannot be responsible for recommendations made or conclusions reached which later prove to be erroneous because of inaccurate or incomplete data or personal information. By signing below and/or by submitting this questionnaire to us by mail, by facsimile, or electronically, you certify that the information supplied in this questionnaire is, to the best of your knowledge, accurate and complete.
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Personal Information

Asset and Liability Information

Household Income

Cash Assets

Tangible Personal Property/Collectibles

Intangible Personal Property

Real Estate

Business Interest

Pension, Profit Sharing, Other Employee Benefits and Annuities

Trust Interests

Expectancies

Miscellaneous Assets

Liabilities

Contingent Liabilities

Taxable Gifts

Stock Options

Insurance Issues

Life Insurance

Disability Insurance

General Liability Umbrella Insurance

Long-Term Health Insurance

Your Estate Planning Concerns

Other Concerns:

Optional:

Acknowledgement