1. Name: type full name Date of Birth: type date Date of Death (if applicable): type date Address: street address city, state zip country Child of a Prior Marriage: Yes No Home Phone: type home phone with area code Cell type cell phone with area code Work Phone: type work phone with area code E-Mail: type preferred email address Adopted Yes No Does This Child Have Special Yes No Please Explain: please explain special needs Relationship: type relationship if not child 2. Name: type full name Date of Birth: type date Date of Death (if applicable): type date Address: street address city, state zip country of a Prior Marriage: Yes No Home Phone: type home phone with area code Cell Phone: type cell phone with area code Work Phone: type work phone with area code E-Mail: type preferred email address Adopted Child: Yes No Does This Child Have Special Needs: Yes No Please Explain: please explain special Relationship: type relationship if not child 3. Name: type full name Date of Birth: type date Date of Death (if applicable): type date Address: street address city, state zip country Child of a Prior Marriage: Yes No Home type home phone with area code Cell Phone: type cell phone with area code Work Phone: type work phone with area code E-Mail: type preferred email address Adopted Child: Yes No Does This Child Have Special Needs: Yes No Please Explain: please explain special needs Relationship: type relationship if not use additional sheet at end of questionnaire if necessary
V. Assets A. Summary Statement (if necessary, attach a separate sheet) Asset C: Client S: Spouse/Other J; Joint T: Trust Financial Institution(s) Amount (or Cash Value for Life Insurance) Checking/Savings type c, s, j, or t financial institution(s) amount Brokerage Accounts type c, s, j, or t financial institution(s) amount Individual Stocks and type c, s, j, or t financial institution(s) amount Retirement Account(s) type c, s, j, or t financial institution(s) amount life insurance type c, s, j, or t financial institution(s) amount Annuities – type c, s, j, or t financial institution(s) amount Annuities – Qualified type c, s, j, or t financial institution(s) amount B. Property Ownership (Provide Copies of Deeds/Stock Certificates) Owner(s) Address Type (e.g., house, condo, co-op) Fair Market Value Mortgage Balance Cost Basis full names of owners street address city, zip country type fmv mortgage balance cost full names of owners street address city, state zip country type fmv mortgage balance cost basis full names of owners street address city, state zip country type fmv mortgage balance cost basis full of owners street address city, state zip country type fmv mortgage balance cost basis VI. Income A. Summary Statement Non-
city, state zip country city, zip country Home home phone with area code Cell cell phone with area code Work work phone with area code Relationship: type relationship Home home phone with area code Cell Phone: cell phone with area code Work Phone: work phone with area code Relationship: type relationship if additional sheets are necessary, please contact the office VIII. Other Information Use this section to provide us with specific instructions regarding your estate plan such as how to distribute your residuary estate, information on residual beneficiaries such as nieces, nephews or charities, general bequests of cash or any other item you can think of that is relevant to preparing your documents. type additional information here (continuation sheet - if necessary) IV. Living and Deceased Children (indicate if deceased by placing “D” next to name) * if you have no children list nieces/nephews/grandchildren and make a note to me 4. Name: type full name Date of type date Date of Death (if applicable): type date Address: street address city, zip country Child of a Marriage: Yes No Home Phone: type home phone with area code Cell Phone: type cell phone with area code Work Phone: type work phone with area code E-Mail: type preferred address Adopted Child: Yes No Does This Child Have Special Needs: Yes No Please Explain: please explain special needs Relationship: type relationship if not child 5. Name: type full name Date of Birth: type date Date of Death (if applicable): type date Address: street address city, state zip Child of a Prior Marriage: Yes No