Estate Planning Questionnaire

Date

Full Legal Name

Preferred First or “Nick” Name

Age

DOB

Citizen? Yes No

Spouse’s Full Legal Name

Preferred First or “Nick” Name

Age

DOB

Citizen? Yes No

Address

City

State

Zip

Employer/Retired?

Your Work #

Spouse’s Employer/Retired?

Spouse’s Work #

Best E-mail Address

Your Cell #

Home #

Spouse’s Cell #

Referral Source
How did you hear about us? Credit union, family member, newspaper, postcard, seminar, friend, legal plan… please designate (example: Bellco):

Children
Below, list full names (and married names, if applicable) of all your children.

If a child is the product of your present marriage, put a “P” in the “Comments” blank.

If a child is the product of husband’s former marriage, put an “H” in the “Comments” blank.

If a child is the product of wife’s former marriage, put a “W” in the “Comments” blank.

If you have particular concerns you would like to discuss about a child, put an “O” in his or her “Comments” blank.

Name(s) of Child(ren)	Age	Single(S) or Married(M)	# of Children	Comments

ASSETS

Please check the blanks corresponding to the various types of assets owned by you and/or your spouse, don’t worry about listing any values here.

Investments [non-IRA and non-401(k) accounts]

Mutual Funds
Stocks
Corporate Bonds
Real Estate Partnerships
Oil & Gas Interest(s)
Privately Owned Business(es)
Gold/Silver/Gemstones
Commodities
Other:

Company Benefits/Retirement Plans

IRA
401(k)
Company Retirement Plan
PERA
Performance Sharing Plan
Stock Option Plan
ESOP
TIAA/CREF/TRASOP
Other:

Life Insurance

Group Policy Through Employer
Privately Owned
Tax Sheltered Annuity
Government/Military
Other:

If You Have a Spread Sheet or Detailed Information – Typed or Handwritten – Concerning Your Assets, Liabilities and Other Financial Information, Please Bring This Information With You to Your Initial Consultation.

DECISION MAKERS

Who among your family members and/or friends would you appoint to handle the estate-settlement details for you at your death or during a mental disability?

You

Your Spouse

First Choice

You

Your Spouse

Second Choice

You

Your Spouse

Third Choice

You

Your Spouse

MOTIVATIONS

We are interested in why you decided to inquire about your estate planning at this particular point in time. Please check one or more of the choices below that correspond with your situation.

Going on vacation soon.
Had a recent death in the family.
Just went to a wills and trust seminar.
Read an article that prompted me into action.
Just had my/our first child.
Getting concerned about death taxes.
Worried about nursing homes and disability.

Got a worrisome medical diagnosis recently.
Would like to avoid probate.
Advised by my Financial Planner to do so.
Just bought my/our first house.
Concerned about irresponsible/disabled kid(s).
Just decided to stop procrastinating!!
Other:

LIFE’S LITTLE PLEASURES

What hobbies, diversions, or activities do you enjoy so we can learn a little bit more about the “real” you, as opposed to just numbers and names (e.g., golf, yoga, crafts, exercise, fishing, hiking, camping, hunting, gardening, shopping, reading, sports, traveling, cooking, antiquing, investing, crosswords, computers, cars, bridge, movies, etc.):

You

Your Spouse

Please Fill The Next Form

Estate Planning Questionnaire

Tell us what’s important to you by ranking each one of the following points on a scale of 1 to 10, with 1 being “Not Important” or “Not Applicable” and 10 being “Very Important.”

Rank (Between 1 to 10)

Name:

1. I want to ensure my spouse gets everything of mine when I die without limitation

2. I would like to make certain that special personal items I own go to selected individuals so there is no confusion or hard feelings after my death

3. I would like to name one or more family members, a good friend or a financial advisor to make my financial decisions if I am too sick or incapacitated to make them on my own

4. I would like to name one or more family members or good friends to make my medical decisions for me if I am too sick or incapacitated to make them on my own

5. I would like my doctor, after consulting with my family, to disconnect the feeding tube and/or ventilator if I am in a terminal condition

6. I would like to provide clear instructions regarding my final wishes and the disposition of my last remains

7. I want to leave a portion of my estate to charity

8. I would like to avoid probate

9. I want to make certain that my personal and financial information remain private at my death or during my disability (i.e., out of the public eye)

10. I want to set aside money for the care of one or more of my pets

11. I would like to protect what I leave to my spouse so that what’s left when he/she dies goes to my children and not my surviving spouse’s potential new spouse and/or stepchildren

12. I want to be sure my children don’t squander their inheritances

13. I would like to protect what I leave my children from their

divorce(s), either current or potential

over-controlling spouses

poor money-management skills

over-generosity

credit card debt, lawsuits or IRS problems

alcohol problems or other substance abuse

medical problems or disabilities (current or potential)

failure to save for retirement

poor business skills

death tax issues (i.e., they already have large estates)

Other:

14. I want my children to get good educations and other financial benefits from my estate

15. I want my grandchildren to get good educations and other financial benefits from my estate

16. I would like to avoid inheritance and estate taxes

17. I would like to make certain that any business I own passes to specific family members or other business associates without confusion

18. I want to protect my assets from a lawsuit in which I am currently involved

19. I want to protect my assets from a lawsuit in which I may later become involved

20. I am worried that someone may sue me within the near future

21. I am worried about having to make good on someone else’s loan where I signed a personal guarantee

22. I would like to protect my estate from nursing home bills if I become chronically ill for a period of time before my death

23. I am worried that I may not have enough income to live comfortably for the rest of my life

24. I am worried that I may run out of money before I die

25. I would like the guidance of a geriatric care expert if my spouse or I need help with long-term care issues

26. I would like to ensure that my documents are kept up-to-date over the years as changes occur

Are there any other issues not addressed above that are important to you?

Thank you. Your form has been submitted

Submit

(303) 758-0680

Estate Planning Questionnaire

ASSETS

Real Estate

Cash Deposits

Investments [non-IRA and non-401(k) accounts]

Company Benefits/Retirement Plans

Life Insurance

DECISION MAKERS

You

Your Spouse

You

Your Spouse

You

Your Spouse

You

Your Spouse

MOTIVATIONS

LIFE’S LITTLE PLEASURES

You

Your Spouse

Estate Planning Questionnaire

Estate Planning is all about

Estate Planning Questionnaire