Estate Planning Questionnaire

Client #1 General Information

Full Legal Name

Date of Birth

Home Address

Address

City

State

Zip Code

Telephone | Fax Number

Cell Phone

Home Phone

Work Phone

Fax Number

Email Addresses

Home Email

Work Email

Occupation

Title

Company Name

Street Address

Work City

State

Zip Code

Country

Client #2 General Information

Full Legal Name

Date of Birth

Home Address

Address

City

State

Zip Code

Telephone | Fax Number

Cell Phone

Home Phone

Work Phone

Fax Number

Email Addresses

Home Email

Work Email

Occupation

Title

Company Name

Street Address

Work City

State

Zip Code

Country

Children/Beneficiaries

Full Legal Name	Relationship	Birthdate (MM/DD/YYYY)	Address	Disability?	Reasonably Possible Future Disability?	Share of Estate(s)

Client #1 Advisors

Type of Advisor	Advisor Name	Name of Firm	Phone

Client #2 Advisors

Type of Advisor	Advisor Name	Name of Firm	Phone

Summary of Assets

Checking, Savings, Money Market

Client #1

Client #2

Title Held (H, W, Both)

Total Value ($)

Certificates of Deposit

Client #1

Client #2

Title Held (H, W, Both)

Total Value ($)

Traditional IRA | 401(k ) | 403(b), etc.

Client #1

Client #2

Title Held (H, W, Both)

Total Value ($)

$ Roth IRA | 401(k)

Client #1

Client #2

Title Held (H, W, Both)

Total Value ($)

Non-Tax Deferred Brokerage Accounts

Client #1

Client #2

Title Held (H, W, Both)

Total Value ($)

Individual Stocks and Bonds

Client #1

Client #2

Title Held (H, W, Both)

Total Value ($)

Life Insurance (Death Benefit Values)

Client #1

Client #2

Title Held (H, W, Both)

Total Value ($)

Life Insurance (Cash Values)

Client #1

Client #2

Title Held (H, W, Both)

Total Value ($)

Real Estate Equity

Client #1

Client #2

Title Held (H, W, Both)

Total Value ($)

Annuties

Client #1

Client #2

Title Held (H, W, Both)

Total Value ($)

Stock Options (Current Value)

Client #1

Client #2

Title Held (H, W, Both)

Total Value ($)

Closely Held Business Interests

Client #1

Client #2

Title Held (H, W, Both)

Total Value ($)

Cars, Boats, Planes, etc.

Client #1

Client #2

Title Held (H, W, Both)

Total Value ($)

Valuable Tangible Personal Property

Client #1

Client #2

Title Held (H, W, Both)

Total Value ($)

Other

Assets

Client #1

Client #2

Title Held (H, W, Both)

Total Value ($)

Totals

Client #1

Client #2

Total Value ($)

Client #1 Estate Plan General Information

This section addresses the information we need to design your custom estate plan. The persons you name in the following sections will act for you if you become disabled and upon your death. All individual persons named should have a history of responsible behavior.

Guardians for Minor Children

If you have children under the age of 18, list in order of preference whom you wish to be guardian of your minor children. The guardians are named in your Will.

First Choice

Name

Relationship

Phone

Second Choice

Name

Relationship

Phone

Executor

The Executor is the person or qualified corporation that is responsible for filing your Will with the probate court and administering your probate estate, if any. Spouses are often the first choice for each other.

First Choice

Name

Relationship

Phone

Second Choice

Name

Relationship

Phone

Third Choice

Name

Relationship

Phone

Client #1 Trustee

If you set up a Living Trust or a Trust established under your Will, the Trustee is the person or qualified corporation that is responsible for managing your assets upon your disability and/or death. Spouses are often the first choice for each other.

First Choice

Name

Relationship

Phone

Second Choice

Name

Relationship

Phone

Third Choice

Name

Relationship

Phone

Power of Attorney for Property | Finances Agent

First Choice

Name

Relationship

Phone

Second Choice

Name

Relationship

Phone

Third Choice

Name

Relationship

Phone

Client #2 Trustee

First Choice

Name

Relationship

Phone

Second Choice

Name

Relationship

Phone

Third Choice

Name

Relationship

Phone

Power of Attorney for Property | Finances Agent

First Choice

Name

Relationship

Phone

Second Choice

Name

Relationship

Phone

Third Choice

Name

Relationship

Phone

Client #1 Power of Attorney for Health Care Agent

The agent for your Power of Attorney for Health Care is the person who makes health care decisions for you if you are not able to communicate decisions yourself. Spouses are often the first choice for each other.

First Choice

Name

Relationship

Phone

Second Choice

Name

Relationship

Phone

Third Choice

Name

Relationship

Phone

Living Will

If you become terminally ill, and such illness is irreversible, and your death is imminent, do you want your doctors to refrain from using heroic measures (i.e., heart-lung machine, feeding tube, etc.) to keep you alive?

lf you answer “YES,” you are indicating that you want a Living Will.
If you answer “NO,” you are indicating that you do not want a Living Will.

Client #1 Living Will

Yes

Client #2 Power of Attorney for Health Care Agent

First Choice

Name

Relationship

Phone

Second Choice

Name

Relationship

Phone

Third Choice

Name

Relationship

Phone

Living Will

lf you answer “YES,” you are indicating that you want a Living Will.
If you answer “NO,” you are indicating that you do not want a Living Will.

Client #2 Living Will

Yes

1. Do you have Long-Term Care Insurance that covers long-term nursing home or in-home nursing care?

Yes

2. Do you expect to receive inheritance?

Yes

3. Is there anything else you would like us to know relative to your estate planning?

Yes

If yes, please describe:

Acknowledgement

The information I have provided herein is accurate to the best of my knowledge. The Law Office of David Watson, LLC may rely on the information herein in preparing my custom estate plan.

Client #1 Signature

Printed Name

Date (MM/DD/YYYY)

Signature

Sign Here

Client #2 Signature

Printed Name

Date (MM/DD/YYYY)

Signature

Sign Here

Client #1 General Information

Home Address

Telephone | Fax Number

Email Addresses

Occupation

Client #2 General Information

Home Address

Telephone | Fax Number

Email Addresses

Occupation

Children/Beneficiaries

Client #1 Advisors

Client #2 Advisors

Summary of Assets

Checking, Savings, Money Market

Certificates of Deposit

Traditional IRA | 401(k ) | 403(b), etc.

$ Roth IRA | 401(k)

Non-Tax Deferred Brokerage Accounts

Individual Stocks and Bonds

Life Insurance (Death Benefit Values)

Life Insurance (Cash Values)

Real Estate Equity

Annuties

Stock Options (Current Value)

Closely Held Business Interests

Cars, Boats, Planes, etc.

Valuable Tangible Personal Property

Other

Totals

Client #1 Estate Plan General Information

Guardians for Minor Children

First Choice

Second Choice

Executor

First Choice

Second Choice

Third Choice

Client #1 Trustee

First Choice

Second Choice

Third Choice

Power of Attorney for Property | Finances Agent

First Choice

Second Choice

Third Choice

Client #2 Trustee

First Choice

Second Choice

Third Choice

Power of Attorney for Property | Finances Agent

First Choice

Second Choice

Third Choice

Client #1 Power of Attorney for Health Care Agent

First Choice

Second Choice

Third Choice

Living Will

Client #2 Power of Attorney for Health Care Agent

First Choice

Second Choice

Third Choice

Living Will

Acknowledgement

Client #1 Signature

Client #2 Signature

Checklist of Documents Needed for Data Gathering