ESTATE PLANNING QUESTIONAIRE

A. Basic Information
1. Your Name: ___________________________________
2. Your Address: ___________________________________
___________________________________
3. County of Residence: ____________________________
4. Telephone Number: _____________________________
5. Email Address: _________________________________
6. Marital Status: Single ___ Married ___ Widowed ___ Divorced ___
7. Spouse's Name: _________________________________
8. If your spouse is deceased, please indicate the date: _____________
9. Are there any previous marriages for you or your spouse? _________
10. Please list the names of your children:
a.__________________________
b.__________________________
c.__________________________
d.__________________________
e.__________________________
f.__________________________
g.__________________________
11. Are any of your children deceased? If so, did they have children?
______________
12. Are you or your spouse a veteran? If so, please list the dates of
service:__________________
13. Are you or your spouse currently receiving Medicaid benefits? _______________
14. Do you own (or are you buying) your home? ___________________
15. Do you own any real estate other than your home? ___________________
B. Estate Information
1. What is the approximate value of your estate (include real estate and
investments): __________
2. Who do you want to manage your estate when you (and your spouse) pass?
_____________________________________
3. If that person is unable or unwilling to act, who do you want in their place?
_____________________________________
4. When you (and your spouse) have passed, do you want your estate divided
between all children
equally? (y/n) ________
5. If not, how do you want your estate distributed?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
6. If a beneficiary should pass before you, should that person's share be divided
up among the
surviving beneficiaries? (y/n) _______
7. Are there any children to disinherit? If yes, which children?
_______________________________________________________________________
______
8. Are there any Special Needs Children that need to be accounted for?
_______________________________________________________________________
______
9. Are there any special bequests or Special Bequests/Gifts you would like to make
when you
pass?
_____________________________________________________________________________
C. Powers of Attorney and Appointment
1. In the event you become incapacitated during your lifetime, we need to name
someone who can
make decisions for you concerning your finances and your health care, and a
successor. Generally
speaking, if you are married, your spouse will be primary automatically, we also
need to name a
successor. This will be:
a. Financial Management: _________________________________
Successor: _________________________________
b. Health Care Management: _________________________________
Successor: _________________________________
2. If you currently have children under the age of 18, or if you have guardianship
or
conservatorship of someone who can not manage their own affairs, we need to
name someone to take
over for you. This will be:
a. Guardianship: _________________________________
Successor: _________________________________
b. Conservatorship: _________________________________
Successor: _________________________________