Estate Planning Questionnaire Estate Planning Questionnaire Please have this Information Packet completed prior to our initial meeting. We would appreciate your providing us with the information prior to our meeting so that we have enough time to understand the specifics of your situation before our meeting. If you need assistance completing the information, call our office at (925) 933-9047 and we will help you. DON’T WORRY ABOUT TOTAL ACCURACY - JUST DO THE BEST YOU CAN WE LOOK FORWARD TO SEEING YOU!!! ALL INFORMATION IS STRICTLY CONFIDENTIALPersonal Profile- Please provide us with information about youClient Full name* First Last Other names used Other names used Home address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County of Residence Home Phone*Work Phone*Cell Phone*Email address* Occupation* Employer Social Security NumberDate of Birth* MM slash DD slash YYYY Period of Residence in CaliforniaLess than a month1-6 months1-3 yearsOver 3 yearsAre you a U.S. Citizen? Yes No Spouse Full name Spouse Full name Last Other names used Other names used Home address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County of Residence Home PhoneWork PhoneCell PhoneEmail address Occupation Employer Social Security NumberDate of Birth MM slash DD slash YYYY Period of Residence in CaliforniaLess than a month1-6 months1-3 yearsOver 3 yearsAre you a U.S. Citizen? Yes No Is there a prenuptial agreement or marital agreement? Yes No Date and place of marriage Marital RelationshipsPrior marriages of Client/SpouseHas Client or Spouse been married before? Yes No Number of prior marriage for ClientSpouseGive the following information for each former marriage:Name of former spouse First Last Date of marriage MM slash DD slash YYYY Was marriage ended by death or divorce? Yes No Date the divorce was final (or date of death)? MM slash DD slash YYYY Children - Please provide us with information about your children.Child(1) Male Female Name First Last Child of Client/Spouse Client Spouse Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NoBirthdate MM slash DD slash YYYY Special Needs of Child Yes No DescribeChild(2) Male Female Name First Last Child of Client/Spouse Client Spouse Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NoBirthdate MM slash DD slash YYYY Special Needs of Child Yes No DescribeChild(3) Male Female Name Name Child of Client/Spouse Client Spouse Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NoBirthdate MM slash DD slash YYYY Special Needs of Child Yes No DescribeChild(4) Male Female Name Name Child of Client/Spouse Client Spouse Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NoBirthdate MM slash DD slash YYYY Special Needs of Child Yes No DescribeChild(5) Male Female Name Name Child of Client/Spouse Client Spouse Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NoBirthdate MM slash DD slash YYYY Special Needs of Child Yes No DescribeAre there any deceased children? Yes No Did they leave any surviving children? Yes No Names and ages of any surviving children of the deceased children If Your Children Are Minors:If you have children under the age of 18, list in order of preference who would raise them and love them in the manner as close as possible to the way you would. If you choose a married couple, you should consider what should happen should the parties divorce.Name, address, and phone number of person to serve as GuardianBackupFinancial Profile - Please provide us with information about your financial situationIncome Husband Wife Joint Monthly Earned Income*Monthly Social Security IncomeMonthly Pension IncomeOther Monthly IncomeList all Real Property (i.e., land or homes) owned by you and how title is held:Please provide “Grant Deeds” for all California real propertyFMVOweTotal Gross:Total Net:CheckingFMVOweSavingsFMVTotal GrossTotal NetAutomobiles, Boats and RV’sFMVOweSecurities (common stock, preferred stock, corporate bonds, mutual funds)FMVOweTotal GrossTotal NetRetirement or other employee benefits including 401(k), IRA or Keogh accounts, include the names of the beneficiaries of these benefitsFMVOweTotal GrossTotal NetLife Insurance which you ownFace value Cash valueType of Policytermwhole lifeName and address of each insurance company and policy number.Business InterestsFMVOweAre you the holder of any promissory notes? Yes No If yes, for each, list name of payor , the name of the payee and the current outstanding balance.*Are you the beneficiary of any trust? Yes No please indicate:Name of the trust Name of the trust Name of the trustee Name of the trustee Value of trust principal and income Any general power of appointments in another persons will or trust? Yes No who?List your tangible personal property of significant valueMiscellaneous Furniture and GoodsFMVOweTotal GrossTotal NetAnticipated Gifts or Lawsuit Judgment (Please describe)Total GrossOther AssetsFMVOweTotal GrossNumberTotal NetSummary of ValuesReal Property CashAutomobiles Securities Retirement Life Insurance Business Interests Notes Inheritance Power of Appointments Personal Property Gifts of Judgments Other Assets TOTAL Total Gross Estate Total Net Estate AdvisorsPersonal AttorneyName Name TelephoneEmail Address AccountanName Name TelephoneEmail Address Financial AdvisorName Name TelephoneEmail Address Life Insurance AgentName Name TelephoneEmail Address Casualty Insurance AgentName Name TelephoneEmail Address Are you happy with your current advisors? Yes No Do you need a referral for any of the above? Yes No Is there an advisor that you believe I should get to know Successor Trustees and Executors: After your death, who do you want carrying out your instructions, for distribution of your estate and, if desired, for management of the property for your beneficiaries. The primary criteria for trustee is trustworthiness. This person should also be good with the management of time and money.First Successor Trustee (or Executor):Name Name Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NoSecond Successor Trustee (or Executor):Name Name Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NoThird Successor Trustee (or Executor)(Optional): Name Name Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NoExecutorsSame as Successor Trustees? Yes No Other Disposition of Your Estate (Who do you want to be your Beneficiaries?)How do you wish the remainder of your estate to be distributed?If you have children:Should your property be divided equally amongst your children? Yes No who or how? Should the trust property be held in trust until a later age? Yes No what age?Under 1818-2425-3435-4445-5455-6465 or AbovePrefer Not to AnswerShould a deceased child’s share go to their children (your grandchildren)? Yes No who or how? Should the trusts property be held in trust until a later age? Yes No what age?Under 1818-2425-3435-4445-5455-6465 or AbovePrefer Not to AnswerAnything else?If you don’t have childrenWho would you like to receive your estate and how much of it should they receive?Is there anyone you wish to specifically disinherit? If so, please indicate belowPlease indicate any specific gifts of real or personal property that you wish to leave to a specific person:Other notesPowers of Attorney for Legal and Financial Affairs: If you were unable to make legal or financial decisions for yourself, who would you want to make those decisions for you?Client: Name, address and telephone number of person you wish to serve as your DPA FinancesSpouse is the first Agent? Yes No First Second Third Add Alternative person you wish to serve as your DPA Finances Advanced Health Care Directive: If you were unable to make health care decisions for yourself, who would you want to make those decisions for you?Client: Name, address and telephone number of person you wish to serve as your DPA HealthSpouse is the first Agent? Yes No First Second Third Special InstructionsDisposition of Remains: Any special burial or funeral instructions for your executor?Client Buried Cremated Other DetailsSpouse Buried Cremated Other DetailsAutopsy: Should your agent have the authority to request an autopsy?Client Yes No Spouse Yes No End of Life Decisions: Do you wish to be kept on life support should you be in an irreversible coma or vegetative state? Client Pull Plug Maintain on Life Support Spouse Pull Plug Maintain on Life Support Relief From Pain: Do you wish the use of medications to alleviate pain and suffering even if they may hasten the moment of death?Client Yes No Spouse Yes No Other Wishes: Do you wish food and hydration to be continued if you are in an irreversible coma?Client Yes No Spouse Yes No Organ Donation: Do you wish to make any anatomical donations?Client Yes No Would you like to limit your donation to your family? Yes No Other Client limitations Spouse Yes No Would you like to limit your donation to your family? Yes No Other Spouse limitations Other Items to Include or Discuss: Your estate plan should address all your hopes, fears and wishes. Please list any other items you would like addressed or covered.Is there anything unique about your situation that the attorney should know about?Anything else?Estate planning document review and signing appointments are typically available Monday through Thursday starting at 8:30 a.m. Afternoon appointments must usually commence by 4:30 p.m. Morning appointments are available on Fridays from 9 a.m. until 1 o'clock p.m. Exceptions are made for emergencies and special circumstances. Please be advised that you have none of the protections an estate plan will provide to you until the documents are actually signed, witnessed and notarized. Completion of this form will not provide you with any protection. Your completed estate planning documents must be signed, witnessed and notarized. Thank you for allowing us to be of service with your estate planning needs!CAPTCHA Δ