* Please Complete All Applicable Fields
General Information
Name (First, Middle, Last):
Email:
Home Address:
City, State, Zip Code:
Home Phone:
Business Phone:
Spouse's Work Phone:
Best Way To Contact: Email Phone
Social Security Number:
Date of Birth:
Martial Status: Married Single Divorced Widowed
Employment Information
Your Employer:
Your Occupation:
Employer's Address:
Employer's City, State, Zip Code:
Spouse's Employer:
Spouse's Occupation:
Spouse's Employer's Address:
Spouse's Employer's City, State, Zip Code:
Personal Information
Are you a U.S. Citizen? Yes No
Is your spouse a U.S. Citizen? Yes No
Do you have a will or trust now? Yes No
Are you expecting to receive property or money from (check all that apply): Gift Lawsuit Inheritance Other
Is your spouse expecting to receive property or money from (check all that apply): Gift Lawsuit Inheritance Other
If so, approximately how much?
Please list your children:
Full Name Age  M Martial Status No. of Grandchildren Adopted? Husband/Wife/Joint
S M D Y N H W J
S M D Y N H W J
S M D Y N H W J
S M D Y N H W J
S M D Y N H W J
Do you have any deceased children? Yes No
Does your spouse have any deceased children? Yes No
If so, how are they related to you and how old are they?
Please list all of your personal property and real property.

Description and Location

Title In Whose Name
(H/W/J)
Purchase
Price
Market
Value
Mortgage

Total Net Value: (line 1)

Financial Information
Please list all of your financial accounts.
Description Title In Whose Name (H/W/J) Market Value Balance

Total Net Value: (line 2)

Please list all of your life insurance policies.
Description Policy Owner Term or
Whole Life
1st Beneficiary 2nd Beneficiary Death Benefit

Total Net Value: (line 3)

Total Net Estate Value (Add lines 1, 2 and 3):
Do you have a safe deposit box? Yes No
Whose name is it under and where is it located? Name: Location:
Are you or your spouse currently guarantors of any loans? Yes No

Supplement to Estate Planning Questionnaire

Trustee(s) - You will be the initial trustee and your spouse is typically named as successor trustee (but not required).
Back-up Trustee(s) - Steps in at your and your spouse's disability or death. Can be your adult children, trusted friends and/or a corporate trustee.
Name Address Phone Number
Guardians For Minor Children - Responsible adult who will raise your children until age 18 if something happens to you and your spouse.
Name Address Phone Number
Beneficiaries
Special Gifts To Individuals or Organizations. Do you want to make a gift (cash or a specific item) to an individual, charity, foundation, religious or fraternal organization?
Name of Person or Organization Description of Gift
Beneficiaries: Who do you want to receive the rest of your estate after these special gifts have been distributed? You can designate a dollar amount or a percentage.

Alternate Beneficiaries: Who do you want to receive your estate if you (and your spouse) outlive the beneficiaries you have named above?
Name of Child/Person Amount/Percentage
Inheriting Instructions. Do you want your children to receive their inheritance in installments, at certain ages, or all at once? Installments
Certain Ages
All At Once
Dependents Who Require Special Care. Do you want to provide for "basic" care or luxuries and other extras to supplement government benefits? Yes
No
Special Instructions For Incompetency
Keeping/Selling Assets. If necessary to pay for your care, do you want certain assets sold first? Are there potential buyers you want contacted? Sell Assets: Yes No
Buyer's Name:
Medical Care. Do you want to be in (or avoid) a certain hospital/nursing home? How do you feel about blood transfusions, organ transplants, life support, etc.?
A Living Will makes your wishes known to family and doctors regarding life support in the event you become terminally ill or injured with no hope for recovery. Do you want a Living Will? You: Yes No
Your Spouse: Yes No
A Durable Power of Attorney gives the person you choose the power to manage all of your financial affairs now, while you are competent, and if you become disabled or incompetent.
Choice 1:
Choice 2:
Special Instructions for Funeral/Burial
What type of service do you want, how elaborate, and where? Any special people to contact? Do you want cremation? If you have a cemetery lot, where is it located?
Questions to ask your attorney about your living trust.
General Questions/Comments:
  I/We have reviewed all the information of this Estate Planning Supplemental Questionnaire and I/we find it to be accurate and complete. I understand that this information will be used in the preparation of my estate plan and my attorney and advisors may rely solely on this statement.