Estate Planning Questionnaire

PAUL B. BARTLETT, P.C.

335 North Wilmot, Suite 410

Tucson, Arizona 85711

(520) 750-1061

http://www.tucsonelderlaw.com

ESTATE PLANNING QUESTIONNAIRE

Please complete the following questionnaire to the best of your abilities. This information is most helpful to us so that we may properly plan for you. Do not be upset if you cannot complete all of the questions. We will review this information at our meeting.

Name (Full name as it should appear in your will)

Husband: ________________________________

Wife: ___________________________________

Date of Marriage: _________________________

Address: _______________________________

_______________________________

Date of Birth

__________

Social Security Number

_____________________

Telephone: Home _______________________

Husband Work ___________________

Wife Work ___________________

Children common to the marriage:

Name

_________________________

Date of Birth

_________

__________

Address

__________________

Social Security #

If Available

_________________

Husband’s children (prior marriage) :

Name

_________________________

Date of Birth

_________

Address

__________________

Social Security #

If Available

_________________

Wife’s children (prior marriage) :

Name

_________________________

Date of Birth

_________

Address

__________________

Social Security #

If Available

_________________

Other persons who are important to your estate plan (grandchildren, siblings, nieces and nephews, etc.)

Name

_______________________________

Date of Birth

___________________

Address

______________________

General Information

Are you covered by Social Security? ( Y, N )

Are you self-employed? ( Y, N )

Do you have a will? ( Y, N )

Date of Will:

Are you the beneficiary of any Trust? ( Y, N )

Do you have a Power of Attorney? ( Y, N )

Husband

__________

Wife

__________

Comments:

Health Care

Do you have: Medicare Part “A” __________________ Medicare Part “B” ________________

Supplemental Insurance _________________________________________________________

Long Term Health Care Insurance _________________________________________________

Do you or any member of your family have any illness or disability which should be considered in planning your estate?

Comments:

Income

Please list your estimated income this year from the following sources:

Annual or Monthly Amounts

Source:

Social Security

Interest

Dividends

Pension Benefits

IRA Benefits

Rental Income

Other Income

Subtotal

Husband

_________________

Wife

_________________

Total Income

_________________________

Do you have any unusual expenses which should be considered in planning your estate?

Comments:

Assets (Summary)

Real Estate

Stocks and Bonds

Bank Accounts

Mortgages & Notes

Personal Property

Life Insurance

Retirement Benefits

Business Assets

Miscellaneous

Subtotal

Husband’s Name

_____________

In Joint Names

_____________

Wife’s Name

_____________

Total Assets

______________________

ASSETS AND LIABILITIES (Detail)

ASSETS: Complete the appropriate sections or attach separate statements such as bank account or brokerage statements, balance sheet, your own list, etc. If assets are not owned jointly by husband and wife, please indicate.

1. Real Estate

Location

_____________________________________

Estimated Value

___________________

Mortgage Balance

________________

Comments:

2. Stocks and Bonds

Number

_____________

Security

(a) Securities Not Held in a Brokerage Account

__________________________

(b) Brokerage Accounts

__________________________

Value

________________

IRA or other tax qualified Plan?

________________

_________________

3. Bank Accounts

Bank

and Account Number

______________________

Type of Account

(checking, CD, money mkt, etc.)

___________________________

Joint Account

(if any)

___________

Balance

__________

Do you maintain a safe deposit box?

Bank ___________________

Branch _________________

Number _________________

4. Promissory Notes, Mortgages

Description

____________________________________________

Value

_______________________________

5. Tangible Personal Property

Estimate the total value of your household furnishings, automobiles,

and other personal belongings:

_____________________

Do you have any items of special value which should be considered in planning your estate?

Comments:

(You will have the opportunity to prepare a separate list to designate certain items of tangible personal property for specific persons, but you need not do this now.)

6. Life Insurance

Insured

(H or W?)

___________

Company

_________________________

Amount

__________________

Beneficiary

________________

7. Retirement Benefits

___________

Description

(a) Pension / Profit Sharing

_________________________

(b) IRA Accounts / 401(k)

_________________________

Amount

__________________

Beneficiary

________________

8. Business Assets

Description

___________________________________________________________

Value

________________

Comments:

9. Miscellaneous

Description

___________________________________________________________

Value

________________

Liabilities

Please list any outstanding liabilities (you need not include ordinary monthly expenses) if not shown elsewhere:

Description

_______________________________________

Amount

_________________

Date Due

________________

NOTE: Documents to bring to our meeting, if available and applicable:

(a) Will(s)

(b) Deed to residence

(c) Powers of Attorney

(d) Insurance policies

(e) Bank or brokerage account statements

(f) Any other documents that you deem relevant