ph: (310) 463-6845
fax: (877) 817-5877
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To get started, please see the Estate Planning Fact Gathering Questionnaire below.
1. Your Preliminary Information (For ALL Estate Planning Clients to Fill out)
Your Full Name: _____________________________ Your Social Security: ______________
Your Date of Birth: ____________
Spouse’s Name: ___________________________ Spouse’s Social Security: ______________
Spouse’s Date of Birth: ____________
Address: __________________________________________________________________
Phone(s): (H) __________________; (W) _________________(Other) _______________
Email: __________________________; _________________________
County of Residence: ____________________
Country of Citizenship: You ____________________ Spouse ___________________
What state were you legally married in: _______________
Include Other Names You have used: _________________________________________
Indicate Maiden Name, if applicable: ___________________
Past Marriages:
Name of Former Spouse: (1) ___________________(2) ___________________
Ended by Death or Divorce: (1) _________________ (2) __________________
Pre-Nuptial Agreement? Yes___ No___ (If yes, please attach copy)
FINANCIAL INFORMATION
The Starting point of the estate planning process requires you to roughly calculate the size and nature of your estate assets. Please specify in the margin if the asset is “community property” (acquired during marriage) or “separate property” (acquired before marriage or inherited during marriage).
0) INCOME
Total Annual Income of Household $ _____________
____________________________________________
1) CASH AND SAVINGS (Please bring bank name, address and account number)
Checking Account $ ___________
Certificates of Deposit (CDs) $ ___________
Savings Account $ ___________
TOTAL CASH AND SAVINGS $ ______________
2) MARKET SECURITIES (Please bring bank name, address and account number)
Stocks $ ___________
Bonds $ ___________
Mutual Funds $ ___________
Annuities $ ___________
TOTAL OF MARKET SECURITIES $ ______________
3) REAL ESTATE (Please list address, city and state)
TYPE OF PROPERTY CITY MARKET VALUE - MORTGAGE = EQUITY
i. ______________________________ ____________________________________
ii. _______________________________ ____________________________________
TOTAL EQUITY IN REAL ESTATE $ _______________
4) FIXED AND OTHER ASSETS
Business Interests $ ___________
Limited Partnerships $ ___________
Other $ ___________
TOTAL OF FIXED AND OTHER $ ________________
5) RETIREMENT PLANS (Please bring bank name, address and account number)
IRA (Standard Deductible) $ ___________ $_____________
401k $ ___________ $_____________
403B $ ___________ $_____________
Profit Sharing Plan $ ___________ $_____________
Other $ ___________ $_____________
TOTAL OF RETIREMENT PLANS $ ________________
6) LIFE INSURANCE (Please list life insurance company and agent, if you know)
Face Value of Policy #1 $ ___________ (Term or Whole Life?)
Face Value of Policy #2 $ ___________ (Term or Whole Life?)
(Also list the beneficiary of each policy)
TOTAL FACE AMOUNT OF LIFE INSURANCE $ ________________
7) OTHER ASSETS (Cars, boats, collectibles, etc.)
$ ___________
$ ___________
TOTAL OF OTHER ASSETS $ ________________
GRAND TOTAL OF ALL ASSETS $_______________
3. Burial Requests and Organ Donation
Do you have any special requests for burial (i.e. cremation or burial)? ______________________ Spouse: ______________
Do you want to be an organ donor? Yes ___ No ____
Spouse: Yes ___ No ____
4. Children (please indicate if child is deceased, adopted, step child, if from a prior
marriage, andif child is handicapped)
Name: DOB: Where born:
i)_________________________ ________ _______________
ii)________________________ ________ _______________
iii)________________________ ________ _______________
iv)________________________ ________ _______________
Who do you want to have Custody of your Children? This is also known as the "Guardian". Include alternate choices please. Although husband and wives are ok, please remember the possibility of death or divorce.
NAME CITY THEY RESIDE IN
i) ___________________ ___________________
ii) ___________________ ___________________
5. Beneficiary Selection
With the exception of establishing a guardian for any underage children, the beneficiary selection is the most crucial aspect of your estate plan. This is where you determine who gets what and how much they get. Although you should take extra time reading through this section, you will likely want to discuss these issues with me in a face to face meeting. Do your best, but don't feel that everything has to be filled out completely.
You may want to begin by jotting down some general thoughts about who you want to get your property. The questions can help make these determinations more concrete. Consider if you die first and if your spouse dies first.
____________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________
PERSONAL PROPERTY-General Gifts. Generally speaking, who do you want the bulk of your personal property (non-monetary or real property assets) such as paintings, collections, furniture, etc. to go to? You have the opportunity in the next question to leave specific items to other people. Feel free to have multiple people (i.e. all living children at your death) to share your personal property.
First Choice: _______________________________________________________________
Second Choice: _____________________________________________________________
PERSONAL PROPERTY- Specific Gifts. If you would like to make specific gifts of personal property, such as art, collectibles, etc., please list the items below and the recipients (with at least one successor person named, in case your first choice person is unable to take the gift). You can not list everything you own in a simple will; it is just not practical. The following items should be pieces of personal property that do not follow the general flow of your personal property (for example, maybe you want your special painting to go to your best friend rather than a spouse or child).
ITEM First Choice Second Choice
1) ________________________________________________________________________
2) ________________________________________________________________________
3) ________________________________________________________________________
4) ________________________________________________________________________
BULK OF PROPERTY. Who do you want to receive the bulk of your assets (money, real property, stocks, bonds, etc.) when you pass away? Feel free to divide up your estate in percentages (for example 30% to child 1, 30% to child 2, 30% to child 3, and 10% to your favorite niece). List back up choices. If unsure, just jot down general notes.
____________________________________________________________________________________________________________________________________________________________
Small gifts of Cash. In addition to the general flow of all your assets, is there anybody you would like to give a small cash gift to upon your death (i.e. $500 to a special niece or nephew)?
1) ________________________________
2) _________________________________
Charitable Gifts. Would you like to make any charitable contributions (which are tax deductible) upon your death? (Religious organizations, schools, fraternal organizations, and other such groups)
1) ________________________________ 2)___________________________________
Disinheritance. Is there anybody you would like to specifically not give assets to at death?
1) ____________________________ 2) _______________________________
Trust Gifts. If we are establishing a trust for minor children, at what age would you like disbursement to be made to the children without the trust restrictions? __________
6. Trustees/Executors
If you are setting up a trust for you, and you are unable to serve as trustee and administer the affairs of the trust, who do you want to serve in the roll of trustee?
1) _____________________________________
2) _____________________________________
3) _____________________________________
8. Other Inheritance Questions
1) Are you or your spouse beneficiaries or trustees of any trust? Yes No
2) Do you or your spouse have a power of appointment under any trust? Yes No
3) Do you or your spouse anticipate receiving an inheritance? Yes No
4) Have you ever filed (or had filed on your behalf) a gift tax return? Yes No
If yes to number 4, please bring copies.
5) Have interest in sole proprietorship, general partnership, limited
partnership or any closely held business? Yes No
6) Have you made gifts of over $12,000 to anybody in any year? Yes No
(Not optional, these are the ancillary documents necessary to complete an estate plan!)
10. Durable Power of Attorney for Financial Affairs
This document gives someone the power to make all sorts of financial decisions for you. These include, but are not limited to the following:
* Most all financial affairs
* Investments
* Make Gifts
* Pay mortgage and other bills
* Conduct Banking
* Deal with Insurance
* Make Loans
* Operate Business
* Personal Care (Where you live, meals, take care of pets, handle mail, provide transportation, etc.)
This power will spring into effect when you are unable to handle your own affairs.
You should indicate your first choice, and successor choices, to hold your power of attorney:
You: Spouse:
1) _______________________ 1) _____________________
2) _______________________ 2) _____________________
11. Durable Power of Attorney for Health Care
This document is similar to the above, but allows someone to make health care related decisions for you. The powers are extensive, and include the ability to:
· Consent or refuse medical care
· Employ and Discharge Doctors
· Consent to or refuse life prolonging procedures
· Protect Right of Privacy
· Prevent pain
· Provide for companionship
You should indicate your first choice, and successor choices, to be your health care Agent:
You: Spouse:
1) _______________________ 1) _____________________
2) _______________________ 2) _____________________
12. Living Will (Health Care Declaration)
The last piece of the estate planning puzzle is the "Living Will" which tells the doctors what you want (or don't want) in the way of life support. This means an incurable and irreversible condition that has been diagnosed by one physician (unless you prefer to have 2 physicians diagnose) and:
- Will result in death within a relatively short time without administration of life- sustaining treatment; or
- Has produced an irreversible coma; or
- Persistent vegetative state.
Generally, I prepare the documents in a similar manner for most everybody. However, we can alter it for your needs if you desire something different. Generally, life support that is cut, if you are no longer able to make decisions regarding medical treatment, include:
- Food and water by artificial administration, even if would prolong life;
- Comfort care, even if would prolong life;
- All additional life-prolonging treatment be withheld, except for:
-Blood and blood products;
- Cardio-pulmonary resuscitation (CPR);
- Diagnostic tests;
- Dialysis;
- Drugs;
- Respirator;
- Surgery
Please initial here if you are in agreement with this ____________
13. Other Thoughts you have about your estate plan? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Thank you for taking the time to fill out this questionnaire. Please call me immediately to set up an appointment to discuss your answers and prepare your documents. –Sonja
ph: (310) 463-6845
fax: (877) 817-5877
sp