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

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)

_________________________

 

_________________________

 

(c)  Annuities

_________________________

 

_________________________

 

_________________________

 

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