Diane L. Rivers Attorney At Law Admitted in NY, NJ and CT CPA, LL.M. in taxation 185 East 85th Street, Suite 3K New York, New York, 10028-2172 Telephone: (212) 722-4084 Fax: (212) 831-3218 Web site: http://www.DianeRivers.com “Of Counsel” to the Bohonnon Law Firm, LLC 205 Church Street, Suite 506 New Haven, Connecticut 06510 E-mail: Diane@DianeRivers.com
CONFIDENTIAL ESTATE PLANNING QUESTIONNAIRE
This Confidential Estate Planning Questionnaire should be returned in advance of our initial estate planning meeting. All information will be kept confidential. This information is necessary to begin the estate planning process. The more detail the better. Add extra pages as needed. Please print clearly all names and addresses so that they can be properly included in any documents. The more complete and accurate this Questionnaire is, the more efficient our initial meeting will be. If you have any questions while filling out this Questionnaire, please call or just note them below for discussion at our meeting. I look forward to working with you. I. Goals. Please explain what you would like to accomplish with your estate plan. Briefly state your objective or concerns. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ II. Background Information. Topic/Item Name to be used on your estate planning documents Yourself __________________________ __________________________ Other names (e.g., nickname, maiden name or other aliases) __________________________ __________________________ Home: Street address (including City/State/Zip Code) __________________________ __________________________ __________________________ County of residence __________________________ Home: Fax number __________________________ __________________________ __________________________ Your Spouse/Partner __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________
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Home: Telephone number __________________________ Business: Occupation/Description (please indicate if sole proprietorship, closely held corporation, LLC, LLP, partnership, etc.) __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________
Business: Street Address (including City/State/Zip Code)
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__________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________
Business: Telephone number __________________________ Business: Fax number __________________________ E-mail address __________________________ Date of birth/Place of birth/age __________________________ __________________________ Social Security Number __________________________ Citizenship __________________________ III. Community Property. Have either of you ever lived in Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas or the State of Washington? If yes, please provide dates and please indicate if you were married during any of these periods. If you were married, please provide information regarding your estate at the time of marriage in such state, the place of marriage, assets acquired during marriage, your domicile at the time of the acquisitions, the source of funds used for such acquisitions and the value of any gifts or inheritances received by you during the marriage: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
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IV. Marital Information.
Topic/Item Current Marital status: Current Marriage: Spouse Name Current Marriage: Date and Place of Marriage Current Marriage: Please provide a copy of the applicable agreements listed.
Yourself Single [] Married [] Widowed [] Divorced [] Separated [] __________________________ __________________________ __________________________ __________________________ [] Prenuptial Agreement [] Postnuptial Agreement [] Other. Please explain. __________________________ __________________________ 1._________________________ __________________________ 2._________________________ __________________________ 3._________________________ __________________________
Your Spouse/Partner Single [] Married [] Widowed [] Divorced [] Separated [] __________________________ __________________________ __________________________ __________________________ [] Prenuptial Agreement [] Postnuptial Agreement [] Other. Please explain. __________________________ __________________________ 1._________________________ __________________________ 2._________________________ __________________________ 3._________________________ __________________________ 1._________________________ __________________________ 2._________________________ __________________________ 3._________________________ __________________________ 1._________________________ __________________________ 2._________________________ __________________________ 3._________________________ __________________________ [] Prenuptial Agreement [] Postnuptial Agreement [] Separation Agreement [] Divorce Agreement [] Other. Please explain.
Prior Marriage(s): Spouse Name
Prior Marriage(s): Date and Place of Marriage
1._________________________ __________________________ 2._________________________ __________________________ 3._________________________ __________________________
Prior Marriage(s): Date and reason of termination.
1._________________________ __________________________ 2._________________________ __________________________ 3._________________________ __________________________
Prior Marriage: Please provide a copy of the applicable agreements.
[] Prenuptial Agreement [] Postnuptial Agreement [] Separation Agreement [] Divorce Agreement [] Other. Please explain.
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V. Information on Your Parents. Topic/Item Name: Your Mother ________________________________ ________________________________ Age: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ Your Father ________________________________ ________________________________ Age: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________
IF LIVING: Street Address (including City/State/Zip Code) Telephone number Description of financial status How parent's estate plan relates to you. Anticipated inheritance Anticipated financial responsibility Are you agent/executor etc.? Please describe. IF NOT LIVING: Date of death Status of probate. Please attach copy of estate tax return. Any trusts or other planning affecting you. Please attach copy.
________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________
________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________
If you have a step parent or adopted parents, please provide the information listed above for such parent on a separate page.
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VI. Information on Your Spouse's/Partner's Parents. Topic/Item Name: Your Spouse's/Partner's Mother ________________________________ ________________________________ Age: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ Your Spouse's/Partner's Father ________________________________ ________________________________ Age: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________
IF LIVING: Street Address (including City/State/Zip Code) Telephone number Description of financial status How parent's estate plan relates to you. Anticipated inheritance Anticipated financial responsibility Are you agent/executor etc.? Please describe. IF NOT LIVING: Date of death Status of probate. Please attach copy of estate tax return. Any trusts or other planning affecting you. Please attach copy.
________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________
________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________
If you have a step parent or adopted parents, please provide the information listed above for such parent on a separate page.
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VII. Information on Your Siblings. (Please attach additional pages if necessary). Name/Relationship Address/ Telephone Age Sex Marital Status/ History/ Spouse's Name ___________ ___________ ___________ ____ F [] M [] ___________ ___________ ___________ ____ F [] M [] ___________ ___________ ___________ ____ F [] M [] ___________ ___________ ___________ ____ F [] M [] ___________ ___________ ___________ ____ F [] M [] ___________ ___________ ___________ ____ F [] M [] ___________ ___________ ___________ Children Names And Ages ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________
1.________________ __________________ __________________ 2.________________ __________________ __________________ 3.________________ __________________ __________________ 4.________________ __________________ __________________ 5.________________ __________________ __________________ 6.________________ __________________ __________________ 7.________________ __________________ __________________
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VIII. Information on Your Spouse's/Partner's Siblings. (Please attach additional pages if necessary). Name/Relationship Address/ Telephone Age Sex Marital Status/ History/ Spouse's Name ___________ ___________ ___________ ____ F [] M [] ___________ ___________ ___________ ____ __________________ __________________ __________________ __________________ 4.________________ __________________ __________________ 5.________________ __________________ __________________ 6.________________ __________________ __________________ 7.________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ ____ F [] M [] ____ F [] M [] ____ F [] M [] ____ F [] M [] ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ F [] M [] ___________ ___________ Children Names And Ages ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________
1.________________ __________________ __________________ 2.________________ __________________ __________________ 3.________________
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IX. Information on Your Children. (Please indicate with a "*" if from a prior marriage and with "**" if adopted). Name/Relationship/ Other Parent Name Address/ Telephone Age Sex Marital Status Any Special Needs ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ Spouse's Name/ Marital History ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________
1.________________ __________________ __________________ __________________ 2.________________ __________________ __________________ __________________ 3.________________ __________________ __________________ __________________ 4.________________ __________________ __________________ __________________ 5.________________ __________________ __________________ __________________ 6.________________ __________________ __________________ __________________ 7.________________ __________________ __________________ __________________ 8.________________ __________________ __________________ __________________
_____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________
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X. Information on Your Spouse's/Partner's Children, if different. (Please indicate with a "*" if from a prior marriage and with "**" if adopted). Name/Relationship/ Other Parent Name Address/ Telephone Age Sex Marital Status Any Special Needs ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ Spouse's Name/ Marital History ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________
1.________________ __________________ __________________ __________________ 2.________________ __________________ __________________ __________________ 3.________________ __________________ __________________ __________________ 4.________________ __________________ __________________ __________________ 5.________________ __________________ __________________ __________________ 6.________________ __________________ __________________ __________________ 7.________________ __________________ __________________ __________________ 8.________________ __________________ __________________ __________________
_____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________
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XI. Information on Your Grandchildren. (Please indicate with a "*" if from a prior marriage and with "**" if adopted). Please attach separate page if there are great-grandchildren. Name/Relationship/ Other Parent Name Address/ Telephone Age Sex Marital Status Any Special Needs ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ Spouse's Name/ Marital History ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________
1.________________ __________________ __________________ __________________ 2.________________ __________________ __________________ __________________ 3.________________ __________________ __________________ __________________ 4.________________ __________________ __________________ __________________ 5.________________ __________________ __________________ __________________ 6.________________ __________________ __________________ __________________ 7.________________ __________________ __________________ __________________ 8.________________ __________________ __________________ __________________
_____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________
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XII. Information on Your Spouse's/Partner's Grandchildren, if different. (Please indicate with a "*" if from a prior marriage and with "**" if adopted). Please attach separate page if there are greatgrandchildren. Name/Relationship/ Other Parent Name Address/ Telephone Age Sex Marital Status Any Special Needs ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ Spouse's Name/ Marital History ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________
1.________________ __________________ __________________ __________________ 2.________________ __________________ __________________ __________________ 3.________________ __________________ __________________ __________________ 4.________________ __________________ __________________ __________________ 5.________________ __________________ __________________ __________________ 6.________________ __________________ __________________ __________________ 7.________________ __________________ __________________ __________________ 8.________________ __________________ __________________ __________________
_____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________
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XIII. Information About Other Possible Beneficiaries For Yourself. Name/Relationship Address/ Telephone Age Sex Marital Status Any Special Needs ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ Spouse's Name/ Marital History ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________
1.________________ __________________ __________________ __________________ 2.________________ __________________ __________________ __________________ 3.________________ __________________ __________________ __________________
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XIV. Information About Other Possible Beneficiaries For Your Spouse/Partner (if different). Name/Relationship Address/ Telephone Age Sex Marital Status Any Special Needs ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ Spouse's Name/ Marital History ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________
1.________________ __________________ __________________ __________________ 2.________________ __________________ __________________ __________________ 3.________________ __________________ __________________ __________________
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XV. Summary Balance Sheet. Please insert estimated fair market value of each asset owned by you. Please indicate if jointly owned assets are owned other than by you and your spouse/partner with a "*". Please provide information regarding the contribution made by each owner to the acquisition of the asset and whether a gift tax return was filed. Please indicate who are the beneficiaries of the retirement and or insurance assets. Please attach additional sheets if necessary. Asset Description Owned by Yourself $ $ $ $ $ $_________ $_________ $_________ Owned by Your Spouse/ Partner $ $ $ $ $ $____________ $____________ $____________ $ $ $ $ $ $__________ $__________ $__________ Owned Jointly $ $ $ $ $ $ Pension Assets $ $ $ $ $ $ Total
Cash: Marketable Securities: Mutual funds: Other liquid assets: Other asset: House value: Mortgage (balance remaining): Net Equity: Location:__________________ Date of acquisition:________ Acquisition cost: Value of any improvements: Total acquisition cost: Vacation Home value: Mortgage (balance remaining): Net Equity: Location:__________________ Date of acquisition:________ Acquisition cost: Value of any improvements: Total acquisition cost: Other real estate value: Mortgage (balance remaining): Net Equity: Location:__________________ Date of acquisition:________ Acquisition cost: Value of any improvements: Total acquisition cost: Annuities IRAs 401(K) plans Pension plans Closely Held Business Net Life insurance Cash value Total Net worth
$_________ $_________ $_________ $_________ $_________ $_________
$____________ $____________ $____________ $____________ $____________ $____________
$__________ $__________ $__________ $__________ $__________ $__________ $ $
$_________ $_________ $_________ $_________ $_________ $_________
$____________ $____________ $____________ $____________ $____________ $____________
$__________ $__________ $__________ $__________ $__________ $__________ $ $
$_________ $_________ $_________ $ $ $ $ $ $ $
$____________ $____________ $____________ $ $ $ $ $ $ $
$__________ $__________ $__________ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
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XVI. Detailed Financial Information. A. For brokerage accounts, please attach a copy of a recent brokerage statement. Please indicate the amount, if any, of any related margin loans. Please provide acquisition dates and estimated original cost or indicate if there is substantial appreciation/depreciation. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ B. For cash, CDs and money market accounts, please attach a copy of a recent bank statement. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ C. For automobiles, art, collectibles or other personal assets, please attach copies of any pertinent documents (e.g., insurance description, bill of sale, appraisal). Please indicate the amount, if any, of any related debts. Please provide acquisition dates and estimated original cost or indicate if there is substantial appreciation/depreciation. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ D. For real estate, please attach copies of any pertinent documents (e.g., deed, cooperative apartment lease, shareholders' agreement, operating agreement or partnership agreement). Please indicate the amount of any mortgage or other related debts. Please indicate the acquisition dates and the cost plus improvements of each property. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ E. For closely held business interests, please attach copies of any pertinent documents (e.g., shareholders' agreement, operating agreement, partnership agreement, financial statements, recent tax return). Please provide a short description of business interest giving the name, location, percentage owned, names and relationship of co-owners, date of acquisition/formation, original cost, value, etc. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
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F. For IRAs, 401(k) plans, pension or other retirement assets, please attach copies of any pertinent documents (e.g., recent brokerage statement, summary plan description). Please provide a copy of any applicable stock option plans. Please indicate who the beneficiary and contingent beneficiary are, if any. Please indicate whether distributions are being taken and the method of distribution, if known. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
G. For debts, liabilities, lines of credit, other than those listed above.
Nature of Debt/Debtor Name ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________
Creditor Name & Address
Amount of loan/unpaid balance __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
Security Collateral __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
Interest Rate/Terms __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
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H. Insurance. 1. Life insurance. For each policy, attach a copy of the first several pages of the policy which describes the coverage. If owned by a trust, please attach a copy of the trust. Please attach additional pages if necessary. Please advise if there has been a change in ownership of a policy and or if there are any outstanding loan balances.
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Type of Policy
Insured
Owner of Policy
Beneficiary (and contingent beneficiary if any) ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________
Cash Value
Death Benefit
Premium
Insurance Carrier/Policy Number
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2. Other insurance. Please indicate what other types of insurance, if any, are presently in force (e.g., health, longterm care, disability, business interruption, etc.). ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
XVII. Existing Estate Planning and Related Documents. For each document listed, please attach a copy of the document as well as any relevant information (e.g., copy of recent trust tax return, copy of gift tax return, copy of recent brokerage statement, etc.).
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Yourself Power of attorney Date signed:_______________________________ Agents named:_____________________________ ________________________________________ ________________________________________ ________________________________________ Location: ________________________________________ Other comments: ________________________________________ ________________________________________ Living will/Health Care Proxy Date signed:_______________________________ Agents named:_____________________________ ________________________________________ ________________________________________ ________________________________________ Location: ________________________________________ Other comments: ________________________________________ ________________________________________ Will Date signed:_______________________________ Agents named:_____________________________ ________________________________________ ________________________________________ ________________________________________ Location: ________________________________________ Other comments: ________________________________________ ________________________________________
Your Spouse/Partner Power of attorney Date signed:_______________________________ Agents named:______________________________ _________________________________________ _________________________________________ _________________________________________ Location: _________________________________________ Other comments: _________________________________________ _________________________________________ Living will/Health Care Proxy Date signed:_______________________________ Agents named:______________________________ _________________________________________ _________________________________________ _________________________________________ Location: _________________________________________ Other comments: _________________________________________ _________________________________________ Will Date signed:_______________________________ Agents named:______________________________ _________________________________________ _________________________________________ _________________________________________ Location: _________________________________________ Other comments: _________________________________________ _________________________________________
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REVOCABLE Trust Date signed:_______________________________ Agents named:_____________________________ ________________________________________ ________________________________________ ________________________________________ Location: ________________________________________ Funded: Yes [] No [] Other comments: ________________________________________ ________________________________________ IRREVOCABLE Trust Date signed:_______________________________ Agents named:_____________________________ ________________________________________ ________________________________________ ________________________________________ Location: ________________________________________ Funded: Yes [] No [] Other comments: ________________________________________ ________________________________________
REVOCABLE Trust Date signed:_______________________________ Agents named:______________________________ _________________________________________ _________________________________________ _________________________________________ Location: _________________________________________ Funded: Yes [] No [] Other comments: _________________________________________ _________________________________________ IRREVOCABLE Trust Date signed:_______________________________ Agents named:______________________________ _________________________________________ _________________________________________ _________________________________________ Location: _________________________________________ Funded: Yes [] No [] Other comments: _________________________________________ _________________________________________
XVIII. General Powers of Appointment. A. Are there any instruments conferring a general power of appointment? 1. For You: Yes [] No [] 2. For Your Spouse/Partner: Yes [] No [] B. Date the general power of appointment was created: 1. For You: _________________________________________ 2. For Your Spouse/Partner: _________________________ C. Approximate value of the property subject to the general power of appointment: 1. For You: __________________________________________ 2. For Your Spouse/Partner: ____________________________
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XIX. Fiduciaries. Who should be designated in Your Estate Planning Documents. Fiduciaries include agents under your durable power of attorney, agents under your living will and health care proxy, executors and trustees under your will and guardians under your will. Please consider naming successor agents in the event the first person is unable to act on your behalf. In choosing an agent for your power of attorney consider the following: (1) Is the person trustworthy? (2) Is the person willing to serve? (3) Where the person lives (4) Does the person have financial and investment expertise? (5) Does the person have conflicts of interest with you (the principal)? (6) Does the person have time to serve? (7) Is there a risk of divorce and/ or family friction (if applicable)? A. Power of Attorney. Name of Person/Relationship 1.____________________________ _____________________________ _____________________________ 2.____________________________ _____________________________ _____________________________ 3.____________________________ _____________________________ _____________________________ 4.____________________________ _____________________________ _____________________________ 5.____________________________ _____________________________ _____________________________ 6.____________________________ _____________________________ _____________________________ Address/Telephone Number ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ Age _____
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B. Living Will/Health Care Proxy. If same as above, please merely refer to the above list of individuals.
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Name of Person/Relationship 1.____________________________ _____________________________ _____________________________ 2.____________________________ _____________________________ _____________________________ 3.____________________________ _____________________________ _____________________________ 4.____________________________ _____________________________ _____________________________ 5.____________________________ _____________________________ _____________________________ 6.____________________________ _____________________________ _____________________________
Address/Telephone Number ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________
Age _____
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C. Will. If same as above, please merely refer to the above list of individuals. Please indicate who should be appointed executor and/or trustee and who should be appointed guardian (if applicable) by inserting "E", "T" and "G" after the name of person. Name of Person/Relationship 1.____________________________ _____________________________ _____________________________ 2.____________________________ _____________________________ _____________________________ 3.____________________________ _____________________________ _____________________________ 4.____________________________ _____________________________ _____________________________ Address/Telephone Number ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ Age _____
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5.____________________________ _____________________________ _____________________________ 6.____________________________ _____________________________ _____________________________
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D. Revocable Trust. If same as above, please merely refer to above list of individuals. Name of Person/Relationship 1.____________________________ _____________________________ _____________________________ 2.____________________________ _____________________________ _____________________________ 3.____________________________ _____________________________ _____________________________ 4.____________________________ _____________________________ _____________________________ 5.____________________________ _____________________________ _____________________________ 6.____________________________ _____________________________ _____________________________ Address/Telephone Number ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ Age _____
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E. Irrevocable Trust. If same as above, please merely refer to above list of individuals.
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Name of Person/Relationship 1.____________________________ _____________________________ _____________________________ 2.____________________________ _____________________________ _____________________________ 3.____________________________ _____________________________ _____________________________ 4.____________________________ _____________________________ _____________________________ 5.____________________________ _____________________________ _____________________________ 6.____________________________ _____________________________ _____________________________
Address/Telephone Number ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________
Age _____
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_____
_____
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XX. Basic Questions Regarding Your Estate Planning Documents.
A. Power of Attorney.
1. Should agents and or alternate successor agents only have authority to act on your behalf if you are disabled (i.e., springing) or should their authority be immediate? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
2. Should any agents be required to act jointly? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
3. Should the last agent be given the authority to appoint a successor? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
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4. Who should be included as recipient of the agent's power to make gifts? a. Spouse [] b. Children [] c. Spouse of children [] d. Grandchildren [] e. Siblings [] f. Spouse of siblings [] g. Other [] ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
5. Should agents be given compensation for acting under your power of attorney? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
B. Living Will/Health Care Proxy.
1. If there is no hope of recovery and no reasonable expectation of a meaningful life, should no heroic measures be specified? a. For You: Yes [] No [] b. For Your Spouse/Partner: Yes [] No [] ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
2. Should nutrition and hydration also be withdrawn? a. For You: Yes [] No [] b. For Your Spouse/Partner: Yes [] No [] ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
3. Do you have any specific requests for funeral or burial arrangements (e.g., cremation)? a. For You: Yes [] No [] b. For Your Spouse/Partner: Yes [] No [] ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
4. Do you have any religious restrictions which should be considered? a. For You: Yes [] No [] b. For Your Spouse/Partner: Yes [] No []
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______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
5. Should organ donations be permitted? Any restrictions? a. For You: Yes [] No [] b. For Your Spouse/Partner: Yes [] No [] ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 6. Do you have any other personal concerns? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
C. Will.
1. Do you wish to make any specific bequest of tangible personal property? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
2. Who should be the recipient of your tangible personal property (e.g., furniture, clothing, automobile, art, etc.)? a. Spouse [] b. Children [] c. Spouse of children [] d. Grandchildren [] e. Siblings [] f. Spouse of siblings [] g. Other [] ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
3. Do you wish to make any charitable bequests or specific dollar (pecuniary) bequests? If so, to whom and when (i.e., at your death or only on the later death of you/your spouse/partner)? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
4. To whom should your remaining estate be distributed? a. Spouse [] outright [] in trust [] b. Children [] outright [] in trust []
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c. Spouse of children [] outright [] in trust [] d. Grandchildren [] outright [] in trust [] e. Siblings [] outright [] in trust [] f. Spouse of siblings [] outright [] in trust [] g. Other [] ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
5. If assets are to be held in trust, please indicate at what ages income and principal distributions should be made: a. Principal distributions: (1) Initial 1/3 at age 25 [] 30 [] 35 [] 40 [] 45 [] 50 [] Other: ___ [] (2) Second 1/3 at age 30 [] 35 [] 40 [] 45 [] 50 [] 55 [] Other: ___ [] (3) Balance at age 35 [] 40 [] 45 [] 50 [] 55 [] Other: ___ []
b. Income distributions: (1) Discretionary until age 18 [] 21 [] 25 [] 30 [] 35 [] Other: ___ [] (2) Mandatory after age 18 [] 21 [] 25 [] 30 [] 35 [] Other: ___ []
6. Should the executor/trustee be required to consider a beneficiary's other sources of income in making discretionary distributions of income and principal? Yes [] No [] Other []. Please state: ______________________________________________________________________________________ ______________________________________________________________________________________
7. If all the beneficiaries named above are not living at the time of your death, where should your assets finally be distributed? a. [] One half to your family line and one half to your spouse's/partner's family line. b. [] Specified family members (e.g., nieces and nephews). ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ c. [] Charity. Which one? For what purpose? Please provide full name and address of the charitable organization. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ XXI. Health-related issues.
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Do either of you or your beneficiaries have any health related problems? Please explain. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ XXII. Prior Gifts. A. Have either of you transferred property to someone other than each other within the past 3 years or transferred property in a trust within the past 5 years? If yes, please provide the following information: Donor Recipient Amount/Type of Property/Trust? Outright? Date Of Gift
B. Gift tax returns filed on ANY prior taxable gifts (pre 1997 and post 1976)? Please provide copies, if available. 1. For You: Yes [] No [] 2. For Your Spouse/Partner: Yes [] No [] XXIII. Other Estates. A. Have you, within the past 10 years, inherited any assets from an estate which paid an estate tax? If yes, please provide the following information: 1. Value of the transferor's estate: _________________________________________ 2. Value of the inherited assets: ___________________________________________ 3. Amount of the estate tax paid in the transferor's estate:______________________
XXIV. Documentation to Bring to the Initial Meeting. Please bring any relevant information (as stated above) to the initial meeting (e.g, copy of deeds, income and gift tax returns, agreements, brokerage statements, old estate planning documents, etc.).
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XXV. Advisors.
A. Accountant. Name:_________________________________________________________________________________ Address:______________________________________________________________________________ ______________________________________________________________________________________ Phone Number:_______________________________________________________________________________
B. Investment Advisor. Name:_________________________________________________________________________________ Address:______________________________________________________________________________ ______________________________________________________________________________________ Phone Number:_______________________________________________________________________________
C. Insurance Advisor. Name:_________________________________________________________________________________ Address:______________________________________________________________________________ ______________________________________________________________________________________ Phone Number:_______________________________________________________________________________
XXVI. Your Signature. I/we understand that the recommendations and advice which you will give to me/us and any documents you prepare, will be based on the accuracy and completeness of the information submitted and disclosures made herein. ____________________________________ Your Signature ______________________________________________ Your Spouse's/Partner's Signature
____________________________________ Date
____________________________________ Date
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Diane L. Rivers Attorney At Law Admitted in NY, NJ and CT CPA, LL.M. in taxation 185 East 85th Street, Suite 3K New York, New York, 10028-2172 Telephone: (212) 722-4084 Fax: (212) 831-3218 Web site: http://www.DianeRivers.com “Of Counsel” to the Bohonnon Law Firm, LLC 205 Church Street, Suite 506 New Haven, Connecticut 06510 E-mail: Diane@DianeRivers.com
DISCLOSURE NOTICE
Diane L. Rivers Privacy Policy
Attorneys, like other professionals who advise on personal financial matters, are now required by a new federal law1 to inform their clients of their policies regarding privacy of client information. Attorneys have been and continue to be bound by professional standards of confidentiality that are even more stringent than those required by this new law. Therefore, I have always protected your right to privacy.
Information Collected
In the course of providing you with income, estate and gift tax and or other tax planning advice, you provide me with significant personal financial information. I may collect this nonpublic personal information from you on my questionnaire or other form, over the telephone, via fax, e-mail and or through in-person meetings with you. This information may also be obtained from a third party with your authorization.
Commitment to Confidentiality
All information that I receive from you is held in the strictest of confidence and is not released to people outside my firm, except as agreed by you or as required under an applicable law.
Safeguarding of your Privacy
I retain records relating to the professional services that I provide so that I am better able to assist you with your professional needs and in, some cases, to comply with professional guidelines. In order to guard your nonpublic personal information, I maintain safeguards that comply with my professional standards. ********************* Please call if you have any questions, because your privacy, my professional ethics, and the ability to provide you with quality services is very important to me.
1
The Gramm-Leach-Bliley Act, Public Law 106-102, signed into law on November 12, 1999 by President Clinton and the Federal Trade Commission’s final privacy rule, 16 CFR 313, published on May 24, 2000.
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