CONFIDENTIAL ESTATE PLANNING QUESTIONAIRE Today’s Date ___/___/_____ GENERAL INFORMATION Client’s Name ________________________ Spouse’s Name ______________________________ Date of Birth _________________________ Date of Birth _________________________ Citizenship _______ State of Residence _____ Citizenship _______ State of Residence _____ General Health _________________________ General Health _________________________ Smoker? ____________ Smoker? ____________ Children’s Names Age Marital Number of Status Children _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ Age Notes (have special needs, prior marriage etc.) _____________________________ _____________________________ _____________________________ ____________________________ _ _____________________________ _____________________________
__________________ __________________ __________________ __________________ __________________ __________________
______ ______ ______ ______ ______ ______
_______ _______ _______ _______ _______ _______
WILLS AND TRUSTS CLIENT Do you have a Will?______ If so when was it updated?_________________________________________ Do you have a Living Trust ______ When was it created? _______________________________________ Have you ever filed for gift tax returns? ______ If so when? _____________________________________ What was the amount of the taxable gift? ____________________________________________________ SPOUSE Do you have a Will?______ If so when was it updated?_________________________________________ Do you have a Living Trust ______ When was it created? _______________________________________ Have you ever filed for gift tax returns? ______ If so when? _____________________________________ What was the amount of the taxable gift? ____________________________________________________ GOALS AND OBJECTIVES What are your most important reasons for establishing an estate plan? ______________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Do you have any special goals or concerns for you family members? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
PAGE 1
Record of Personal Assets & Liabilities ASSETS DESCRIPTION
Cash Stocks & Stock Options Taxable Bonds Tax-exempt Bonds Mutual Funds Notes Other Marketable Securities Annuities Limited Partnership Interest Primary Personal Residence Other Residence Other Real Estate
YOURS
SPOUSE’S
JOINT
Business Interests Collectibles/Other Assets IRA’s 401(k), 403(b), Pensions Nonqualified Retirement Life Insurance Face Amount of Ins Cash value of Insurance Other TOTAL ASSETS LIABILITES Credit Card Debt Personal Loans Other Short Term Debt Home Mortgage Real Estate Mortgage Auto Loans Business Debt Other Long Term Debt TOTAL LIABILITIES $ $ $
NET ESTATE Total assets-total liabilities
$
$
$
GERSTEN FINANCIAL inc. Phone : 800-925-7991 Fax : 781-449-7694