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 |