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)

1. 2. 3. 4. 5. 6. 7. 8. 9.

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