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ESTATE PLANNING DATA QUESTIONNAIRE
YOU
Full Name ___________________________________________________
Also Known As _______________________________________________
Drivers License Number _______________________________________
Birthdate_____________________________________________________
Social Security Number _______________________________________
Business Address _____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
E-Mail Address________________________________________________
Business Phone Number ______________________________________
Home Address _______________________________________________
________________________________________________
________________________________________________
________________________________________________
Home Phone Number _________________________________________
Home County ________________________________________________
Date Completed ______________________________________________
SPOUSE
Full Name ___________________________________________________
Also Known As _______________________________________________
Drivers License Number ______________________________________
Birthdate_____________________________________________________
Social Security Number _______________________________________
CHILDREN
Children's Names Birthdates Marital Status # of Children Ages
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
CORPORATE DATA
Corporate Name ______________________________________________
Shareholders # Shares Owned
________________________________________ __________________
________________________________________ __________________
________________________________________ __________________
Officers Title
________________________________________ __________________
________________________________________ __________________
________________________________________ __________________
________________________________________ __________________
Directors
________________________________________ __________________
________________________________________ __________________
* * * * * * * * * * * * * * * * * * * * * * * * * *
SUMMARY OF FINANCIAL INFORMATION
Ownership and Current Estimated Values
ASSETS: You Spouse Joint
Homestead ____________ ____________ ______________
Vacation Home ____________ ____________ ______________
Other Real Estate ____________ ____________ ______________
Closely Held Business Interests:
#1____________ ____________ ____________ ______________
#2 ____________ ____________ ____________ _____________
#3 ____________ ____________ ____________ _____________
Marketable Stocks & Bonds
____________ ____________ _____________
Cash & Equivalents ____________ ____________ _____________
Cars ____________ ____________ _____________
Household goods, furnishings & personal property
____________ ____________ _____________
* Face Value of Insurance:
On your life owned by you
____________ ____________ _____________
On spouse's life owned by spouse
____________ ____________ _____________
* IRAs ____________ ____________ _____________
* Retirement Plans ____________ ____________ _____________
Other Assets ____________ ____________ _____________
(Describe) ____________ ____________ _____________
____________ ____________ _____________
____________ ____________ _____________
Total Assets: $___________ $___________ $____________
* * * * * * * * * * * * * * * * * * * * * * * * * *
LIABILITIES: You Spouse Joint
Homestead Mortgage ____________ ____________ ____________
Business Debt (not included in value of business above)
____________ ____________ ____________
Insurance Loans ____________ ____________ ____________
Other Debts ____________ ____________ ____________
Total Liabilities: $___________ $___________ $___________
NET WORTH: $___________ $___________ $___________
* * * * * * * * * * * * * * * * * * * * * * * * * *
SUPPLEMENTAL INFORMATION
ALL LIFE INSURANCE
#1 Company Type of Policy* Owner Insured
_________________________________________________________
Beneficiary Cash Value Face Value
_________________________________________________________
#2 Company Type of Policy* Owner Insured
_________________________________________________________
Beneficiary Cash Value Face Value
_________________________________________________________
#3 Company Type of Policy* Owner Insured
_________________________________________________________
Beneficiary Cash Value Face Value
_________________________________________________________
#4 Company Type of Policy* Owner Insured
_________________________________________________________
Beneficiary Cash Value Face Value
_________________________________________________________
#5 Company Type of Policy* Owner Insured
_________________________________________________________
Beneficiary Cash Value Face Value
_________________________________________________________
* E.g., whole life, term group, split dollar
* * * * * * * * * * * * * * * * * * * * * * * * * *
LONG TERM CARE INSURANCE
Company Insured
_____________________________________________________________
Daily or Monthly Benefit Benefit Period Waiting Period
_____________________________________________________________
RETIREMENT AND DEATH BENEFITS
IRA Accounts:
Bank or Institution Amount Beneficiary
You _________________ _________________ _______________
_________________ _________________ _______________
Spouse _________________ _________________ _______________
_________________ _________________ _______________
Pension, Profit Sharing or other Retirement Plans: **
You Employer Type of Plan
_____________________________________________________
Estimated Present Death Benefit Beneficiary
_____________________________________________________
Spouse Employer Type of Plan
_____________________________________________________
Estimated Present Death Benefit Beneficiary
_____________________________________________________
** E.g., stock bonus plans (including ESOPs), 401(k) plans, Keogh or HR-10 plans and tax sheltered annuities.
Your benefits administrator should be able to confirm the nature and
estimated amount of your death benefits and the name(s) of the
beneficiaries you have designated.
* * * * * * * * * * * * * * * * * * * * * * * * * *
ESTATE PLANNING INFORMATION
Yes No
Do you and your spouse presently have wills? ________ ________
If yes, indicate date executed and bring them to your initial meeting.
___________________________________________________________
Do you or your spouse own any property jointly with any other person?
________ ________
Is it likely that your estate or your spouse's estate will grow significantly in the next few years because of appreciation, additional insurance, or other reasons?
________ ________
Do you or your spouse presently own real estate or tangible personal property located outside of your state of residency?
________ ________
If yes, what state(s)?
____________________________________________________________
Have you or your spouse made gifts to any person or entity in excess of $10,000 per year prior to 2002, $11,000 per year after 2001 or $12,000 per year after 2005?
________ ________
Are you or your spouse a beneficiary or trustee of any trusts?
________ ________
Does any member of your family have special needs, for example, because of ill health?
________ ________
Have you or your spouse ever been divorced? If yes, do you have financial obligations from prior marriages?
________ ________
Did you and your spouse sign any pre-marriage agreement? If yes, bring them to your initial meeting.
________ ________
Are you a U.S. citizen? ________ ________
Is your spouse a U.S. citizen? ________ ________
In the event of your death, who should have control over management and any decision to retain or sell your closely held business?
______________________________________________________________
Do you want trusts for your children or grandchildren, and, if so, how long should the trusts continue?
______________________________________________________________
Who should receive your estate if neither your spouse nor any of your dependents (children, grandchildren, etc.) is living?
______________________________________________________________
Who should administer your estate or any trusts?
______________________________________________________________
Who should act as guardian(s) for your minor children, if any?
______________________________________________________________
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We ask that you bring the following information with you when you meet with us:
- Most recent corporate income tax return for closely held business
- Most recent year end financial statements for closely held business
- Any buy-sell agreements for closely held business
- Most recent income tax return
- Most recent IRA or 401(k) statement
- Prior Wills or Trust Agreements
- Beneficiary designations for your life insurance policies and retirement plans
- Any pre-marriage agreements
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