ESTATE PLANNING QUESTIONNAIRE

LAST NAME

FIRST NAME

EMAIL ADDRESS

PHONE #

OCCUPATION

STREET ADDRESS

CITY

STATE STATEALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

COUNTY

ZIP CODE

SPOUSE/PARTNER LAST NAME

SPOUSE/PARTNER FIRST NAME

SPOUSE/PARTNER EMAIL ADDRESS

SPOUSE/PARTNER PHONE #

SPOUSE/PARTNER OCCUPATION

DO YOU HAVE CHILDREN (INCLUDING STEPCHILDREN AND/OR FOSTER CHILDREN)? DO YOU HAVE CHILDREN (INCLUDING STEPCHILDREN AND/OR FOSTER CHILDREN)?YESNO

NAME OF CHILD #1

CITY, STATE OF RESIDENCE

PHONE #

CHILD WITH SPOUSE OR OTHER? CHILD WITH SPOUSE OR OTHER?SPOUSESTEP CHILDADOPTED CHILDOTHER

IS THE CHILD MARRIED? IS THE CHILD MARRIED?MARRIEDSINGLEDIVORCED

NAME OF CHILD #2

CITY, STATE OF RESIDENCE

PHONE #

CHILD WITH SPOUSE OR OTHER? CHILD WITH SPOUSE OR OTHER?SPOUSESTEP CHILDADOPTED CHILDOTHER

IS THE CHILD MARRIED? IS THE CHILD MARRIED?MARRIEDSINGLEDIVORCED

NAME OF CHILD #3

CITY, STATE OF RESIDENCE

PHONE #

CHILD WITH SPOUSE OR OTHER? CHILD WITH SPOUSE OR OTHER?SPOUSESTEP CHILDADOPTED CHILDOTHER

IS THE CHILD MARRIED? IS THE CHILD MARRIED?MARRIEDSINGLEDIVORCED

NAME OF CHILD #4

CITY, STATE OF RESIDENCE

PHONE #

CHILD WITH SPOUSE OR OTHER? CHILD WITH SPOUSE OR OTHER?SPOUSESTEP CHILDADOPTED CHILDOTHER

IS THE CHILD MARRIED? IS THE CHILD MARRIED?MARRIEDSINGLEDIVORCED

NAME OF CHILD #5

CITY, STATE OF RESIDENCE

PHONE #

CHILD WITH SPOUSE OR OTHER? CHILD WITH SPOUSE OR OTHER?SPOUSESTEP CHILDADOPTED CHILDOTHER

IS THE CHILD MARRIED? IS THE CHILD MARRIED?MARRIEDSINGLEDIVORCED

NAME OF CHILD #6

CITY, STATE OF RESIDENCE

PHONE #

CHILD WITH SPOUSE OR OTHER? CHILD WITH SPOUSE OR OTHER?SPOUSESTEP CHILDADOPTED CHILDOTHER

IS THE CHILD MARRIED? IS THE CHILD MARRIED?MARRIEDSINGLEDIVORCED

ARE ANY OF THE ABOVE CHILDREN TO BE SPECIFICALLY OMITTED FROM YOUR WILL? ARE ANY OF THE ABOVE CHILDREN TO BE SPECIFICALLY OMITTED FROM YOUR WILL?YESNO

IF SO, PLEASE LIST

ARE YOU OR YOUR SPOUSE A BENEFICIARY OF A TRUST? ARE YOU OR YOUR SPOUSE A BENEFICIARY OF A TRUST?YESNOI AM NOT SURE

HAVE YOU SIGNED A PRENUPTIAL AGREEMENT? HAVE YOU SIGNED A PRENUPTIAL AGREEMENT?YESNOI AM NOT SURE

LIQUID ASSETS (cash, saving account(s), checking account(s), money market account(s), certificated of deposit, etc.)

LOCATION

APPROXIMATE VALUE

LIQUID ASSETS (cash, saving account(s), checking account(s), money market account(s), certificated of deposit, etc.)

LOCATION

APPROXIMATE VALUE

LIQUID ASSETS (cash, saving account(s), checking account(s), money market account(s), certificated of deposit, etc.

LOCATION

APPROXIMATE VALUE

ASSETS (notes, profit sharing, IRA's, annuities, life insurance, etc.)

IS THERE A DESIGNATED BENEFICIARY? IS THERE A DESIGNATED BENEFICIARY?YESNO

IF SO, PLEASE LIST BENEFICIARY

ASSETS (notes, profit sharing, IRA's, annuities, life insurance, etc.)

IS THERE A DESIGNATED BENEFICIARY? IS THERE A DESIGNATED BENEFICIARY?YESNO

IF SO, PLEASE LIST BENEFICIARY

ASSETS (notes, profit sharing, IRA's, annuities, life insurance, etc.)

IS THERE A DESIGNATED BENEFICIARY? IS THERE A DESIGNATED BENEFICIARY?YESNO

IF SO, PLEASE LIST BENEFICIARY

DO YOU OWN PROPERTY IN THE STATE OF FLORIDA? DO YOU OWN PROPERTY IN THE STATE OF FLORIDA?YESNO

LOCATION

VALUE

LOCATION

VALUE

DO YOU OWN PROPERTY OUTSIDE THE STATE OF FLORIDA? DO YOU OWN PROPERTY OUTSIDE THE STATE OF FLORIDA?YESNO

LOCATION

VALUE

LOCATION

VALUE

NOMINATION FOR YOUR PERSONAL REPRESENTATIVE NOMINATION FOR YOUR PERSONAL REPRESENTATIVESPOUSE/PARTNEROTHER

PERSONAL REPRESENTATIVE

ALTERNATE PERSONAL REPRESENTATIVE

SPOUSE/PARTNER'S NOMINATION FOR PERSONAL REPRESENTATIVE? SPOUSE/PARTNER'S NOMINATION FOR PERSONAL REPRESENTATIVE? SPOUSE/PARTNEROTHER

PERSONAL REPRESENTATIVE

ALTERNATE PERSONAL REPRESENTATIVE

DISTRIBUTION OF ESTATE UPON DEATH DISTRIBUTION OF ESTATE UPON DEATHALL TO SPOUSEEQUAL SHARES TO CHILDREN% SHARES TO BENEFICIARIESOTHER

SPOUSE/PARTNER DISTRIBUTION OF ESTATE UPON DEATH SPOUSE/PARTNER DISTRIBUTION OF ESTATE UPON DEATHALL TO SPOUSEEQUAL SHARES TO CHILDREN% SHARES TO BENEFICIARIESOTHER

BURIAL INSTRUCTIONS IF KNOWN

SPOUSE/PARTNER BURIAL INSTRUCTIONS IF KNOWN

COMBINATION LIVING WILL & HEALTH CARE SURROGATE DESIGNATION COMBINATION LIVING WILL & HEALTH CARE SURROGATE DESIGNATIONSPOUSE/PARTNEROTHER

NAME

PHONE

ADDRESS

ALTERNATE NAME

PHONE

ADDRESS

SPOUSE/PARTNER COMBINATION LIVING WILL & HEALTH CARE SURROGATE DESIGNATION SPOUSE/PARTNER COMBINATION LIVING WILL & HEALTH CARE SURROGATE DESIGNATIONSPOUSE/PARTNEROTHER

NAME

PHONE

ADDRESS

ALTERNATE NAME

PHONE

ADDRESS

POWER OF ATTORNEY POWER OF ATTORNEYSPOUSE/PARTNEROTHER

NAME

PHONE

ADDRESS

ALTERNATE NAME

PHONE

ADDRESS

SPOUSE/PARTNER POWER OF ATTORNEY SPOUSE/PARTNER POWER OF ATTORNEY SPOUSE/PARTNEROTHER

NAME

PHONE

ADDRESS

ALTERNATE NAME

PHONE

ADDRESS

DISPOSITION OF AGENT TO CONTROL REMAINS DISPOSITION OF AGENT TO CONTROL REMAINS SPOUSE/PARTNEROTHER

NAME

ALTERNATE NAME

SPOUSE/PARTNER DISPOSITION OF AGENT TO CONTROL REMAINS SPOUSE/PARTNER DISPOSITION OF AGENT TO CONTROL REMAINS SPOUSE/PARTNEROTHER

NAME

ALTERNATE NAME

HOW DID YOU HEAR ABOUT US? HOW DID YOU HEAR ABOUT US? FAMILY/FRIEND ATTORNEY REFERRAL GOOGLE OTHER SEARCH ENGINE FACEBOOK AD SOCIAL MEDIA AVVO MARTINDALE AVVO OTHER

NAME OF ATTORNEY REFERRAL

OTHER