Estate Planning Questionnaire

Name of Husband:

Name of Wife:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County:

Residence Phone:

Cell Phone:

Work Phone:

Prior Marital History / Children:

Number of Children:

Child Name:

Child Date of Birth:

Child Name:

Child Date of Birth:

Child Name:

Child Date of Birth:

If Husband Survives, Outright to Husband:

Family Trust (Husband Primary Benf/ Children Secondary Benf/ and receive Principal upon husband's death):

Other:

Specific Bequests:

If Wife Survives, Outright to Wife:

Family Trust (Wife Primary Benf./ Children secondary benf and receive Principal upon wife's death):

Other:

Specific Bequests:

UNDER AGE TRUST(S) - ( Allows for assets to be managed by Trustee until child / children reach a certain age(s) in the event both parents are deceased ) Children Under Age:

Distribution Age(s):

Guardian of Minor Children:

County/State of Residence of Guardian of Minor Children:

Second Guardian of Minor Children:

Second County/State of Residence of Guardian of Minor Children:

Husband's Executor:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Successor Executor:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Wife's Executor:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Trustee of Children's Trust:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Successor Trustee:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Husband's Durable Power of Attorney (Y or N):

If Yes, Name:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County:

Phone

Wife's Durable Power of Attorney (Y or N):

If Yes, Name:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County:

Phone:

Medical Power of Attorney for Husband:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Second Medical Power of Attorney for Husband:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Directive to Physicians & Family Surrogates (Living Will) : Husband (Y or N):

Directive to Physicians & Family Surrogates (Living Will) : Wife (Y or N):

Gift by a Living Donor: Husband (Y or N):

Gift by a Living Donor: Wife (Y or N):

Contingent Beneficiaries ( in the event that all members of the family, i.e. Husband, Wife, Children do not survive each other):

Please list approximate net value of combined estate and types of assets ( i.e. business, life insurance, retirement plans, etc. ) as this will help us in any other planning requirements:

The Wealth Advisor

The Wealth Counselor

Estate Planning Questionnaire