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Law
Office of Marilyn Sullivan
CONFIDENTIAL ESTATE PLANNING QUESTIONNAIRE
PART ONE: INFORMATION
ABOUT YOU AND YOUR FAMILY
Your name:_______________________________________________
aka____________________
Social Security Number: _____________________________ Date of Birth: ___________________
Spouse's name (if applicable): _________________________________ aka __________________
Social Security Number: _____________________________ Date of Birth: ___________________
Address: ____________________________ City: ___________________ County:
____________
State: ________________ Zip __________ Phone: _______________ (H) _______________
(W)
Are you a U.S. citizen? Yes _____ No _____ Is your spouse a citizen? Yes
_____ No _____
Marital status: Married _____ Unmarried _____ Date of marriage: __________________________
Any previous marriages (indicate number for each): Yourself ________ Your
Spouse ________
If any previous marriages, please indicate name(s) of former spouse(s);
date of termination of each
previous marriage; reason for termination (death/dissolution); whether
it was yours or your spouse's.
______________________________________________________________________________
______________________________________________________________________________
Any living children of your current marriage? If so, please list Name,
sex and birthdate
______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Any deceased children of your current marriage? If so, please list Name,
sex and birthdate
_______________________________________________________________________________
_______________________________________________________________________________
Any children (of either you or your spouse) from a previous marriage?
If so, please list name, sex,
birthdates, and other parent's name by each child.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
PART TWO: INFORMATION
ABOUT YOUR ASSETS (When indicating title, CP = community property,
SP = separate property, JT = joint tenancy and TIC = tenancy-in-common)
Real Estate: Value $___________
STREET ADDRESS ---- AP# ------ VALUE ---------- COST ---
LOAN AMOUNT ----- TITLE
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
** Bring copies of deeds including legal descriptions to meeting.
Closely-Held Businesses:
Value $___________
NAME -------
LOCATION -- TYPE OF ENTITY (Proprietorship, etc.) -- VALUE -- LOAN AMOUNT
-- TITLE
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
** Is there a buy-sell agreement or restriction on transfer of shares?
BRING DOCUMENTS.
Partnership Interests: Value $___________
NAME --- LOCATION ------ TYPE OF PARTNERSHIP (General or
Limited) ------ VALUE ------------ COST ----------- TITLE
_______________________________________________________________________________
** Is there a buy-sell agreement or restriction on transfer of shares?
BRING DOCUMENTS.
Stocks and Bonds: Value $___________
COMPANY OR BROKERAGE NAME (# of shares, if applicable)
----- ACCOUNT # (if applicable) ----------- TITLE
_________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
** Bring copies of certificates, if in your possession, and copies of
monthly statements.
Mutual Funds: Value $___________
NAME OF FUND ------------ ACCOUNT NUMBER ------- TITLE
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
** Bring copies of certificates, if in your possession, and copies of
last monthly statement.
Treasury Bonds / T-Bills / Savings Bonds: Value $___________
TYPE -------
ACCOUNT NUMBER (if applicable) ------- TITLE
_________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
** Bring copies of certificates, if in your possession, and copies of
last monthly statement.
Bank Accounts: Value $___________
BANK NAME -------- TYPE OF ACCOUNT --- ACCOUNT NUMBER
------- TITLE
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
** Bring copies of last monthly statement.
Safe Deposit Box:
LOCATION/ADDRESS /NUMBER
Promissory Notes:
Value $___________
PROPERTY ADDRESS (if secured) -----NAME(S) OF MAKER(S)
------ORIGINAL LOAN AMOUNT -------TITLE
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
** Bring copy of notes.
Retirement Plans
(IRAs, Keoghs, Pension Plans, Annuities, etc.): Value $___________
PLAN NAME ------ NAME OF INSTITUTION ------ ACCOUNT NUMBER
--------------------------BENEFICIARY
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
** Bring copies of last monthly statement.
Life Insurance
Policies: Value $___________
INSURANCE COMPANY ----- POLICY NUMBER ----- TYPE OF POLICY
----- FACE VALUE ----- BENEFICIARY
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
** Bring copies of last monthly statement.
Vehicles, Cars,
Motor Homes: Value $___________
ASSET ------------------------------------ VALUE -------------
COST ------------ TITLE
_________________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Other Miscellaneous Assets (personal, household, etc.): Value $___________
ASSET ------------------------------------ VALUE -------------
COST ------------ TITLE
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Any Marital Settlement Agreements/ Pre-Marital Agreements? If so,
describe and bring with you to meeting.
________________________________________________________________________________
________________________________________________________________________________
NOTES
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
PART THREE: FIDUCIARIES (Trustees/Executors/Guardians/Attorneys-in-Fact/Health
Care Agents)
List below those persons whom you wish to name as trustees of your living
trust, executors of your
will(s), guardians (of minor children or pets), and holders of your powers
of attorney for property
management and for health care. Please read the attached Guidelines for
Choosing an Agent before you proceed. Note that a trustee may also be
a beneficiary. You may name two or more persons for these positions. If
you have any questions, please discuss with us before you decide.
Names of Trustees ---- City ------------ State ---Zip Code --Relationship
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Names of Executors ---- City ------------ State ---Zip
Code --Relationship
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Names of Guardians ---- City ------------ State ---Zip
Code --Relationship
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
For Yourself:
Health Care Agents ---- City ------------ State ---Zip Code --Relationship
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Financial Care Agents ---- City ------------ State ---Zip Code
--Relationship
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
For Your Spouse:
Health Care Agents ---- City ------------ State ---Zip Code --Relationship
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Financial Care Agents ---- City ------------ State ---Zip Code
--Relationship
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PART FOUR: DISTRIBUTION OF YOUR ESTATE Please indicate the desired
distribution of the property in your trust estate upon your death. If
you have any questions, please allow us to assist you in filling in this
information.
1. Indicate desired distribution. For married couples, upon the death
of the second of you to die. For unmarried persons, upon your death.
Distribution
of Specific Asset(s) to Particular Individual(s) (other than
personal property):
Asset to be Distributed -------Beneficiary(ies) (and percentages,
if applicable) --------------------------- Outright or In Trust?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Distribution of Balance of Your Estate:
_____ Distribution in equal shares to your children; if any are deceased,
his or her share to be distributed to his or her issue by right of representation
OR
_____ Distribution to your children (or other beneficiaries) in specific
percentages:
Name of Beneficiary ---------------------------------------------------
Percentage
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________
_____ Trusts for any minor beneficiaries?
If so, distribution in how many stages? ______ 1 ______ 2 ______ 3
Age(s) of distribution for minor trusts:
Stage 1 ________ Stage 2 (if any) ______ Stage 3 (if any) ______ ______
_____ If spouses have differing bequests, check here and note differences
below.
_______________________________________________________________________________
_______________________________________________________________________________
2. For married couples, indicate any gifts to someone other than spouse
at either spouse's death prior to death of surviving spouse.
_______________________________________________________________________________
_______________________________________________________________________________
Other Distribution Provisions
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Questions
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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