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Estate Planning
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Financial Powers of Attorney
Health Care Powers of Attorney & Living Wills
Estate Administration
Guardianships
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Timothy W. Jones
Attorney
Rebecca K. Branz
Attorney
Kristyn G. Whitaker
Attorney
Daniel C. Bensley
Attorney
Mackenzie M. Mills
Attorney
Kathryn N. Landis
Attorney
Breanna M. Combs
Attorney
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ESTATE PLANNING QUESTIONNAIRE
Questionnaire for
INDIVIDUALS
1
Personal Info
2
Assets
3
Nominations
4
Nominations (cont.)
5
Final Comments
Please include full legal name (including full middle name) for each person named on this questionnaire.
Personal Information
Full Name
*
Address
Date of Birth
County of Residence
Employer
Job Title
Home Phone
Mobile Phone
Work Phone
Email
U.S. Citizen?
Yes
No
Marital Status
Single (never been married)
Widow/widower
Married
Separated
Divorced
Engaged
Children
(Names, addresses, phone numbers & dates of birth. Indicate children from prior relationship)
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Assets
Describe any assets other than retirement accounts, life insurance and annuities. Indicate the value and whether it is owned by you, by your spouse or jointly. Include all real property (including your home) and indicate the balance of any mortgage. Include bank accounts.
Description
Value
Owner
Description
Value
Owner
Description
Value
Owner
Description
Value
Owner
Description
Value
Owner
Description
Value
Owner
Description
Value
Owner
Description
Value
Owner
Describe any life insurance policies, retirement accounts and annuities.
Description
Owner/Policy Holder
Value
Primary Beneficiary
Secondary Beneficiary
Description
Owner/Policy Holder
Value
Primary Beneficiary
Secondary Beneficiary
Description
Owner/Policy Holder
Value
Primary Beneficiary
Secondary Beneficiary
Description
Owner/Policy Holder
Value
Primary Beneficiary
Secondary Beneficiary
Description
Owner/Policy Holder
Value
Primary Beneficiary
Secondary Beneficiary
Description
Owner/Policy Holder
Value
Primary Beneficiary
Secondary Beneficiary
Description
Owner/Policy Holder
Value
Primary Beneficiary
Secondary Beneficiary
Have you signed a prenuptial agreement, postnuptial agreement, or separation agreement?
Yes
No
If so, please bring a copy to our initial meeting.
Does any member of your family have special needs or receive government assistance of any kind?
Yes
No
If so, please explain.
If so, please explain.
Do you own an interest in a closely-held business ?
Yes
No
If so, please provide the name and describe type of entity (e.g. LLC or S-corporation).
If so, please provide the name and describe type of entity (e.g. LLC or S-corporation).
Do you have long-term care insurance?
Yes
No
Would you estimate the value of all of your assets, including life insurance, to be greater than $5 million?
Yes
No
Do you have an existing Will or other estate planning documents?
Yes
No
If so, please provide them prior to our meeting or bring them to our meeting
Estate Planning Goals
We will discuss your estate planning goals in detail at our meeting. To assist in preparing for the meeting, please explain in your own words who you want to benefit from your estate when you pass away. (For example, "All of my estate goes to my surviving spouse, and if I have no surviving spouse, to my children in a trust.")
Nominations
Please identify potential candidates to serve important roles in your estate plan. We will explain these roles and discuss your selections in greater detail in our meeting.
Guardian of your minor children
A Guardian is a person(s) you nominate to provide for the care and custody of your minor children until they become adults. Minor children will typically reside with the Guardian(s) in their home. Under its inherent authority to look after the best interests of the child, the Clerk of Superior Court must approve any Guardian nominated.
If you have minor children, whom would you want to nominate as their Guardian?
First Choice (full name)
Relationship
Second Choice (full name)
Relationship
Trustee of Trust
A Trustee is a person(s) or other representative (including a Trust Company) who has the legal title over and responsibility to manage property for the benefit of a designated person(s). Trustee(s) are often used to manage property for minor children until they attain the age chosen by their parents.
Whom would you want to serve as Trustee?
First Choice (full name)
Relationship
Second Choice (full name)
Relationship
Nominations
Please identify potential candidates to serve important roles in your estate plan. We will explain these roles and discuss your selections in greater detail in our meeting.
Executor
Definition of an Executor: An Executor is a person(s) or other representative (including a Trust Company) you appoint under your Will to be responsible for administering your estate. An Executor's duties include filing your Will at the Courthouse after your death, gathering your assets, paying your debts, and distributing property to your beneficiaries. They are also responsible for preparing certain tax returns after your death.
First Choice (full name)
Relationship
Second Choice (full name)
Relationship
Durable Power of Attorney
A Power of Attorney enables another person to manage your financial affairs when you are not able to do so.
Hidden
Would you like a Power of Attorney?
Yes
No
First Choice (full name)
Relationship
Second Choice (full name)
Relationship
Health Care Power of Attorney/Living Will
A Health Care Power of Attorney enables another person to make health care decisions for you when you are not able to do so.
Hidden
Would you like a Health Care Power of Attorney?
Yes
No
First Choice (full name)
Relationship
Home Phone
Work Phone
Mobile Phone
Address
Second Choice (full name)
Relationship
Home Phone
Work Phone
Mobile Phone
Address
In the Health Care Power of Attorney/Living Will, you have the option to express your desires concerning life-prolonging measures (for example, ventilator or artificial nutrition) in the event that you are terminally ill and unable to make your own health care decisions. We will discuss your options at our meeting.
Three options available to you include:
1. Authorizing the person you are naming in the Health Care Power of Attorney to make decisions about life-prolonging measures.
2. Directing your physician to withhold or discontinue life-prolonging measures.
3. Directing your physician to provide you with maximum treatment, including life-prolonging measures.
Final Comments
Are you currently working with an attorney at our firm?
*
Yes
No
If so, which one?
If so, which one?
Were you referred to our firm?
Yes
No
If so, by whom?
If so, by whom?
Do we have permission to contact you?
Yes
No
Additional Comments
