ESTATE PLANNING QUESTIONNAIRE by z8OBCl

VIEWS: 4 PAGES: 22

									ESTATE PLANNING QUESTIONNAIRE

        CONFIDENTIAL
The information supplied in response to this questionnaire is protected by the attorney-client privilege,
and will be held in the strictest confidence. It will be used only for formulation of recommendations to
you for estate planning. It will not be revealed to anyone outside the firm unless authorized by you.




                                              Page 1 of 20
                   ESTATE PLANNNING QUESTIONNAIRE – INDIVIDUAL

                                     Dated: ___________________

                               I. PERSONAL AND FAMILY DATA

A.   Client

     Legal Name                        ___________________________________

     Alias or Former Name(s)           ___________________________________

     Home Address             Street: ___________________________________
                              City: ___________________________________
                              County: ___________________________________
                              State: ___________________________________

     Home Telephone                    ___________________________________

     Home Email                        ___________________________________

     Mobile Telephone                  ___________________________________

     Date of Birth                     ___________________________________

     Place of Birth                    ___________________________________

     Citizenship                       ___________________________________

     Social Security Number            ___________________________________

     Employer (if retired, former)     ___________________________________

     Position                          ___________________________________

     Business Address         Street: ___________________________________
                              City: ___________________________________
                              State: ___________________________________

     Business Telephone                ___________________________________

     Fax Number                        ___________________________________

     Business E-mail                   ___________________________________

                                             Page 2 of 20
If you have been married before, please furnish the following information as to each prior marriage:

        Name of Former Spouse           ___________________________________

        Date and Place of the Marriage ___________________________________

        Place, Date, and Cause          ___________________________________
        (death, Divorce, etc.) of       ___________________________________
        Termination of the Marriage     ___________________________________

        Divorce Obligations to or       ___________________________________
        from Former Spouse (if any)     ___________________________________

        Please provide a copy of any agreement or judicial order respecting a divorce.




                                               Page 3 of 20
B.      Children

Please indicate whether any child or grandchild is the husband’s only (H), wife’s only (W), or a child of
both (B) following the child’s name.

1.      Child:                   Name            _____________________________
                                 Address         _____________________________
                                                 _____________________________
                                 Occupation      _____________________________

        Child’s Spouse:          Name            _____________________________
                                 Address         _____________________________
                                                 _____________________________
                                 Occupation      _____________________________

        Child’s Children         Name            _____________________________
        (your grandchildren)     Address         _____________________________
                                                 _____________________________
                                 Occupation      _____________________________

                                 Name            _____________________________
                                 Address         _____________________________
                                                 _____________________________
                                 Occupation      _____________________________

                                 Name            _____________________________
                                 Address         _____________________________
                                                 _____________________________
                                 Occupation      _____________________________

                                 Name            _____________________________
                                 Address         _____________________________
                                                 _____________________________
                                 Occupation      _____________________________




                                               Page 4 of 20
2.   Child:                 Name          _____________________________
                            Address       _____________________________
                                          _____________________________
                            Occupation    _____________________________

     Child’s Spouse:        Name          _____________________________
                            Address       _____________________________
                                          _____________________________
                            Occupation    _____________________________

     Child’s Children       Name          _____________________________
     (your grandchildren)   Address       _____________________________
                                          _____________________________
                            Occupation    _____________________________

                            Name          _____________________________
                            Address       _____________________________
                                          _____________________________
                            Occupation    _____________________________

                            Name          _____________________________
                            Address       _____________________________
                                          _____________________________
                            Occupation    _____________________________

                            Name          _____________________________
                            Address       _____________________________
                                          _____________________________
                            Occupation    _____________________________




                                         Page 5 of 20
3.   Child:                 Name          _____________________________
                            Address       _____________________________
                                          _____________________________
                            Occupation    _____________________________

     Child’s Spouse:        Name          _____________________________
                            Address       _____________________________
                                          _____________________________
                            Occupation    _____________________________

     Child’s Children       Name          _____________________________
     (your grandchildren)   Address       _____________________________
                                          _____________________________
                            Occupation    _____________________________

                            Name          _____________________________
                            Address       _____________________________
                                          _____________________________
                            Occupation    _____________________________

                            Name          _____________________________
                            Address       _____________________________
                                          _____________________________
                            Occupation    _____________________________

                            Name          _____________________________
                            Address       _____________________________
                                          _____________________________
                            Occupation    _____________________________




                                         Page 6 of 20
4.   Child:                 Name          _____________________________
                            Address       _____________________________
                                          _____________________________
                            Occupation    _____________________________

     Child’s Spouse:        Name          _____________________________
                            Address       _____________________________
                                          _____________________________
                            Occupation    _____________________________

     Child’s Children       Name          _____________________________
     (your grandchildren)   Address       _____________________________
                                          _____________________________
                            Occupation    _____________________________

                            Name          _____________________________
                            Address       _____________________________
                                          _____________________________
                            Occupation    _____________________________

                            Name          _____________________________
                            Address       _____________________________
                                          _____________________________
                            Occupation    _____________________________

                            Name          _____________________________
                            Address       _____________________________
                                          _____________________________
                            Occupation    _____________________________




                                         Page 7 of 20
If any of your children are adopted or from a previous marriage, please describe:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________


Are there any special circumstances affecting you or any of your descendants (health status,
special education requirements, etc.?)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________




                                            Page 8 of 20
C.    Persons Financially Dependent on Client (Not Listed Above)

1.    Name                         ___________________________________
      Address                      ___________________________________
                                   ___________________________________
      Date of Birth                ___________________________________
      Relationship                 ___________________________________

2.    Name                         ___________________________________
      Address                      ___________________________________
                                   ___________________________________
      Date of Birth                ___________________________________
      Relationship                 ___________________________________

3.    Name                         ___________________________________
      Address                      ___________________________________
                                   ___________________________________
      Date of Birth                ___________________________________
      Relationship                 ___________________________________

4.    Name                         ___________________________________
      Address                      ___________________________________
                                   ___________________________________
      Date of Birth                ___________________________________
      Relationship                 ___________________________________

Comments:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________




                                         Page 9 of 20
D.   Other Family Members

1.   Parents

     Father                 Name            _____________________________
                            Age or Year
                            of Death        _____________________________
                            Address         _____________________________
                                            _____________________________
                            Occupation      _____________________________

     Mother                 Name            _____________________________
                            Age or Year
                            of Death        _____________________________
                            Address         _____________________________
                                            _____________________________
                            Occupation      _____________________________

2.   Siblings

     Name                          ___________________________________
     Address                       ___________________________________
                                   ___________________________________
     Age or Year of Death          ___________________________________
     Spouse (if Married)           ___________________________________
     Children (if any)             ___________________________________
                                   ___________________________________

     Name                          ___________________________________
     Address                       ___________________________________
                                   ___________________________________
     Age or Year of Death          ___________________________________
     Spouse (if Married)           ___________________________________
     Children (if any)             ___________________________________
                                   ___________________________________

     Name                          ___________________________________
     Address                       ___________________________________
                                   ___________________________________
     Age or Year of Death          ___________________________________
     Spouse (if Married)           ___________________________________
     Children (if any)             ___________________________________
                                   ___________________________________



                                          Page 10 of 20
Comments on Family Circumstances not Indicated Above
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________




                                     Page 11 of 20
                                       II. FINANCIAL DATA

If you have a recent, comprehensive financial statement which includes all of the information requested
below, please simply attach the statement to this Questionnaire and skip this Item II.

A.     Assets

                                                                       Approximate Value
       Average Cash Balance (including checking, savings, and
       deposit certificates but not including retirement assets)       __________________

       Securities (including publicly traded stocks, bonds,
       and mutual funds but not including retirement assets)           __________________

       Primary Residence
             Value                     __________________
             Mortgage                  __________________
             Equity                                                    __________________

       Other Real Estate

                Description    ________________________________________________
                Value                 __________________
                Mortgage              __________________
                Equity                                          __________________

                Description    ________________________________________________
                Value                 __________________
                Mortgage              __________________
                Equity                                          __________________

                Description    ________________________________________________
                Value                 __________________
                Mortgage              __________________
                Equity                                          __________________

       Automobiles, Boats, or Planes                           Approximate Value
1.     ___________________________________                            __________________
2.     ___________________________________                            __________________
3.     ___________________________________                            __________________
4.     ___________________________________                            __________________




                                             Page 12 of 20
        Livestock                                                       Approximate Value
1.      ___________________________________                             __________________
2.      ___________________________________                             __________________
3.      ___________________________________                             __________________
4.      ___________________________________                             __________________

        Other Assets                                                    Approximate Value
1.      ___________________________________                             __________________
2.      ___________________________________                             __________________
3.      ___________________________________                             __________________
4.      ___________________________________                             __________________
5.      ___________________________________                             __________________

        Life Insurance
1.      Insurance Company               ___________________________________
        Policy No.                      ___________________________________
        Type of Policy                  ___________________________________
        Present Beneficiary             ___________________________________
        Approximate Cash Value          ___________________________________
        Death Benefit                   ___________________________________
        Annual Premium                  ___________________________________

2.      Insurance Company               ___________________________________
        Policy No.                      ___________________________________
        Type of Policy                  ___________________________________
        Present Beneficiary             ___________________________________
        Approximate Cash Value          ___________________________________
        Death Benefit                   ___________________________________
        Annual Premium                  ___________________________________

3.      Insurance Company               ___________________________________
        Policy No.                      ___________________________________
        Type of Policy                  ___________________________________
        Present Beneficiary             ___________________________________
        Approximate Cash Value          ___________________________________
        Death Benefit                   ___________________________________
        Annual Premium                  ___________________________________

If any insurance policy listed above is owned by someone other than you, or was acquired before
marriage, or after marriage by gift or inheritance, please identify with an asterisk and provide details.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________


                                              Page 13 of 20
Retirement Assets/Employment Benefits

                               Description                      Approximate Value
Traditional IRAs        _______________________                 _________________

Roth IRAs               _______________________                 _________________

401 (k) Plan            _______________________                 _________________

Pension Plan            _______________________                 _________________

Thrift Plan             _______________________                 _________________

Profit-Sharing Plan     _______________________                 _________________

Other benefits, such as non-qualified deferred compensation or stock options:

Description                                                     Approximate Value

_________________________________________                       _________________

_________________________________________                       _________________

_________________________________________                       _________________

_________________________________________                       _________________


Person to contact for information at place of employment:
        Name _____________________________
        Phone _____________________________
        Email _____________________________




                                      Page 14 of 20
        Closely Held Business Interests (partnerships, proprietorships, closely held corporations):
Please provide general information relating to the ownership, nature, and value of your business and
proposed or existing arrangements relating to disposition of the interest of an owner upon death.

        Description                                                         Value

        _________________________________________                           _________________

        _________________________________________                           _________________

        _________________________________________                           _________________

        _________________________________________                           _________________

        Potential Inheritance or Gifts

        Description/Anticipated Source                                      Expected Value

        _________________________________________                           _________________

        _________________________________________                           _________________

        _________________________________________                           _________________

         Beneficiary or fiduciary assets: If you are the beneficiary of a trust or have a power or fiduciary
position respect to any trust, or have any estate in property for life, please provide a general description of
the circumstances and approximate value as well as a copy of the trust agreement or deed.

        Description                                                         Value

        _________________________________________                           _________________

        _________________________________________                           _________________

        _________________________________________                           _________________

        _________________________________________                           _________________




                                                Page 15 of 20
B.      Liabilities
                                                                          Approximate Liability

        1.       Accounts payable (including credit cards)                _________________

        2.       Any loans or debts other than those mortgages show in Part A above:

        Description                                                       Approximate Liability

        _________________________________________                         _________________

        _________________________________________                         _________________

        _________________________________________                         _________________

        _________________________________________                         _________________

(Place an asterisk (*) by any debt or mortgage which is covered by credit life insurance.)

C.      Summary of assets and liabilities

        Total Assets (including death benefit of life insurance
        and retirements assets                                            _________________

        Total Liabilities (other than mortgages taken into
        account above)                                                    (________________)

        Net                                                               _________________

D.      Income

        Annual Compensation                                               _________________

        Any annual income in excess of compensation

        Description                                                       Value

        _________________________________________                         _________________

        _________________________________________                         _________________

        _________________________________________                         _________________

        _________________________________________                         _________________

                                               Page 16 of 20
                                     III. MISCELLANEOUS DATA

A.   Please provide contact information for the following individuals.

     The accountant or other person who prepares your income tax return:
                    Name             ____________________________________
                    Address          ____________________________________
                                     ____________________________________
                    Telephone        ____________________________________

     Your insurance agent:
                    Name             ____________________________________
                    Address          ____________________________________
                                     ____________________________________
                       Telephone     ____________________________________

     Your stock broker:
                    Name             ____________________________________
                    Address          ____________________________________
                                     ____________________________________
                       Telephone     ____________________________________

     Your banker or other financial advisor
                    Name             ____________________________________
                    Address          ____________________________________
                                     ____________________________________
                    Telephone        ____________________________________

B.   Have you always lived in Texas?                  _______________________

     If not, in what year did you move to Texas?      _______________________

C.   Do you have a safety deposit box?                _______________________

     If so, with what bank?          ____________________________________

     Listed in whose name?           ____________________________________

     Location of key                 ____________________________________




                                           Page 17 of 20
D.       If you have at any time made donative transfers other than customary gifts (birthday, holiday,
etc., and such transfers were in amounts in excess of $13,000, please indicate the dates, recipients, and
values of the transfers, the general nature of the gift property. If you have filed any United States gift tax
returns, please provide copies.

        Date               Description/Recipient                                     Value

        _________          ______________________________________ __________

        _________          ______________________________________ __________

        _________          ______________________________________ __________

        _________          ______________________________________ __________

        _________          ______________________________________ __________

E.      Military Service

        Branch                    ______________________________________

        Serial No.                ______________________________________

        Dates of Service          ______________________________________

        Reserve Status            ______________________________________

F.       Do you currently have an executed will, trust, power of attorney, directive to physicians, or other
estate planning instrument?     ________________________________

        If yes, please provide a copy of any such document.




                                                   Page 18 of 20
                                       VI. DISPOSITION OF PROPERTY

A.     Generally, how do you want your property to pass upon your death?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________


B.     If any intended beneficiary of your estate is not a citizen of the United States, please indicate.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________




                                                Page 19 of 20
                                V. SELECTION OF FIDUCIARIES

A.     Primary Estate Planning

        List below the person (or bank or other corporate fiduciary) that you wish to have serve in the
following fiduciary capacities. If more than one person or entity is to serve at the same time, please
indicate.

       Executor of Your Will                   ___________________________________

       Alternate Executor                      ___________________________________

       Trustee for Children/Grandchildren      ___________________________________

       Alternate Trustee for Children/
       Grandchildren                           ___________________________________

       Guardian for Minor Children             ___________________________________

       Alternate Guardian for Minor
       Children                                ___________________________________

B.     Ancillary Estate Planning Documents

         Please indicate which (if any) of the following ancillary estate planning documents you are
interested in and provide the name, address, and telephone number of the persons that you wish to
designate as your agent (if required).

____   1.      Statutory Durable Power of Attorney (designates agent to make financial decisions for
               you)

               Primary Agent ___________________________________

               Alternate Agent ___________________________________

____   2.      Medical Power of Attorney (designates an agent to make health care decisions for you in
               the event of incapacity)

               Primary Agent ___________________________________

               Alternate Agent ___________________________________

____   3.      Directive to Physicians and Family or Surrogates (also known as a “Living Will” –
               provides directives regarding the provision of life-sustaining medical treatment)

____   4.      Statement regarding Anatomical Gift (provides for organ donation upon your death)

____   5.      HIPAA Authorization and Release (allows health care providers to release your private
               medical information)


                                             Page 20 of 20
____   6.   Appointment of Agent to Control Disposition of Remains (provides specific directions
            for the disposition of your remains and designates an agent to provide for such
            disposition.

            Primary Agent ___________________________________

            Alternate Agent ___________________________________

____   7.   Declaration of Guardian in the Event of Later Incompetence or Need of Guardian
            (designates an individual to serve as the legal guardian of your person (to make personal
            decisions) and/or of your estate (to make financial decisions) if the need arises)

            Primary Agent ___________________________________

            Alternate Agent ___________________________________




                                          Page 21 of 20

								
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