Estate Planning Questionnaire

CONFIDENTIAL FAMILY DATA

GENERAL BACKGROUND

Full first, middle & last name:

Name as you wish to appear in legal documents:

Other Names Used:

First name (nickname) customarily used:

Home address:

Occupation:

Employer or firm:

Business address:

Phone: (1) Home; (1) (1)

(2) Business: (2) (2)

Email Address(es)

Birth: (1) Date: (1) (1)

(2) Place: (2) (2)

Citizenship:

Social Security No.

Military service (include dates):

Branch and rank attained:

MARITAL/PARTNER RELATIONSHIPS

Current or Former spouse’s/partner’s name

Date/place of marriage/relationship

Terminated by (date): Death: Death:Please provide a copy of the Decree of Dissolution and any related Agreements

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Divorce obligations to or from former spouse/partner:

Child support:

Alimony:

Life Ins.:

Other:

CHILDREN AND DECEASED CHILDREN

1. Name as it will appear in documents:

Birth date:

Place of birth:

Indicate if from prior marriage or adopted:

Name of his/her spouse/partner (if applicable):

Name and birth dates/ages of his/her children:

Special needs:

2. Name as it will appear in documents:

Birth date:

Place of birth:

Indicate if from prior marriage or adopted:

Name of his/her spouse (if applicable):

Name and birth dates/ages of his/her children:

Special needs:

Add additional pages for other children if needed

PARENTS

Name Address: Age (or date of death)

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Brothers & sisters Address: Age(or date of death)

Are any persons (other than minor children) partially or wholly dependent upon you for support now or possibly in the future?

Are any inheritances likely to be received in the future?

ADVISORS

Other Attorney:

Name

Firm

Address

Telephone

Specialty

Accountant:

Name

Firm

Address

Telephone

Similar information should be provided for other bank officers, investment advisors, stockbroker, life insurance advisor, general insurance advisor, physicians, clergyman and personal secretary. For lack of space, this portion of the form is not included here.


PRIOR ESTATE PLANNING

1. Have you had previous wills or estate planning documents prepared?

If so, please provide copies.

2. List here the name of each presently existing trust* of with you (or any child) is a beneficiary, trustee, or grantor:

3. Have gift tax returns ever been filed: *

4. “Community Property/Living Together Agreement” (if one exists) Date executed:

a. Specific property covered:

b. Wish to revoke existing Property Agreement:

Yes [ ]No [ ]

CURRENT ESTATE PLAN

1. Are especially important (or unusual) estate planning objectives (or problems)?

2. Do you own (or have an interest in) real property outside of Washington? Yes No

If so, please provide the mailing address, phone number and proposed disposition in the event of death.

3. Have you guaranteed any loans? Yes No

Will Provisions

1. Personal Representative(s)—person who will take charge at your death:

Alternate(s):

2. Trustee(s)—person who will administer any Trust established by your will:

* A copy of each trust document (with recent list of trust assets) and of each gift tax return should accompany this data sheet. They will be returned.


Alternate(s):

3. Guardian(s) of Minor(s):a. Estate—person who would take

charge of any assets for your minor children received outside your will:

b. Person—person who would take care of your children

(does not have to be the same as 3.a):

Alternate(s):

4. Specific bequests:

5. Residue of estate

___Outright to _______________________

___In trust to ________________________

___Children (see below for trust provisions)

___Other __________________________________________________________________________________________________________________

6. Distribution of Trust Estate (only applicable if Will includes trust for children):

a. Age of youngest child before first distribution:

b. Age for distribution:

(1) First portion:

(2) Second portion:

(3) Third portion:

7. Contingent beneficiary(ies)/charity to inherit if all named beneficiaries are predeceased:

___________________________________________________________________________________________


Durable Power of Attorney. The Durable Power of Attorney is a document which would become effective either upon signing or upon the proven incompetency of an individual to handle his own affairs. The value of this document is that it would avoid the necessity of a guardianship in the event of incompetency.

Effective on signing: Effective on incapacity:

Financial Durable Power of Attorney:

1. Attorney-in-fact(s):2. Alternate(s):

Health Care Durable Power of Attorney:

1. Attorney-in-fact(s):2. Alternate(s):

If you choose separate persons for health care and asset decisions, list those persons below:

1. Asset Attorney-in-fact(s):

Alternate(s):

2. Health Care Attorney-in-fact(s):Alternate(s):

Medical Care Power of Attorney: (Special Limited Power of Attorney authorizing medical care for minor children in parents’ absence.)Authorized Person(s):

Living Will: (to avoid futile treatment in case of terminal illness)

Already have: [ ]

Wish to discuss: [ ]General power of attorney: Already have: [ ]

Wish to discuss: [ ]Anatomical bequests: Yes [ ]

No [ ]If yes, does this include research and education?

Yes [ ]

No [ ]Funeral preferences:

Burial or cremation:

CONFIDENTIAL ASSET AND DEBT LIST


(use this or your own form of financial statement)

Approximate date of report (and values) __________________, 20___

Columns indicate how each asset is owned (or debt owed). Show approximate present market value.

ASSETS (briefly itemize)

Pension plans, profit sharing plans, IRAs, HR-10s (copies of account statements, plan summaries, etc. will help) (attach additional if necessary)

Real estate

Cash values of all owned life insurance****

Bank accounts

Securities (stocks, bonds, etc.)

Personal and household articles (any major items?)

Other assets (closely-held business(es), interests, partnership interests, deferred compensation rights, etc.)

Life insurance—Include both cash value and face value for each policy

TOTAL ASSETS

Debts (mortgages, loans, etc.)

NET ASSETS

LIFE INSURANCE

**** Report life insurance on separate form.


Approximate date of report (and values): ______________, 20____

Company Policy Number

Owner Name Insured Name

Beneficiary Face Amount

PENSION PLANS/ INDIVIDUAL RETIREMENT ACCOUNTS

Description Owner Value Beneficiary


Documents

Estate Planning Questionnaire