BEATTY & MILLER, P.C.
ESTATE PLANNING QUESTIONNAIRE
Date Received ___________
IT IS EXTREMELY IMPORTANT THAT THE FAMILY DATA AND ASSETS LISTED ON THE INVENTORY CHECKLIST ARE FULLY DISCLOSED AND ACCURATE IN ORDER FOR OUR LAW FIRM TO BE INFORMED IN ORDER TO PROVIDE YOU WITH OUR PROPER ADVICE.
FAMILY DATA
1. Name: Birth Date: SSN: ________________
Occupation: _______________________ Citizenship: ______ USA ______ Other
Spouse=s Name: Birth Date: SSN: ________________
Occupation: _______________________ Citizenship: ______ USA ______ Other
2. Home Address _____________________________________ Telephone: ____________________
Street Cell:
___________________________________, _________ _________________
City State Zip
3. Business Address____________________________________ Telephone: ___________________
Street
___________________________________, _________ _________________
City State Zip
4. Spouse Business____________________________________ Telephone: ___________________
Address Street
___________________________________, _________ _________________
City State Zip
5. Email Addresses
Any other state which may be considered a domicile, such as apartment or house maintained elsewhere (including summer home) or voting address in other state? If so, please provide information:
6. Do you have:
A. A Will? Husband: Yes ( ) or No ( ) Please provide a copy.
Wife: Yes ( ) or No ( ) Please provide a copy.
B. General Financial Power of Attorney? Husband: Yes ( ) or No ( ) Please provide a copy.
Wife: Yes ( ) or No ( ) Please provide a copy.
C. Durable Power of Attorney for Health Care Decisions?
Husband: Yes ( ) or No ( ) Please provide a copy.
Wife: Yes ( ) or No ( ) Please provide a copy.
D. Declaration Concerning Life-Sustaining Procedures (a Living Will)?
Husband: Yes ( ) or No ( ) Please provide a copy.
Wife: Yes ( ) or No ( ) Please provide a copy.
7. Names and birth dates of children:
PARENTS
NAME BIRTH DATE (H, W, J)
A. __________________________ ___________ __________
B. __________________________ ___________ ___________
C. __________________________ ___________ ___________
D. __________________________ ___________ ___________
8. Advisors:
A. Attorney: _________________________ Address: _____________________________
Telephone: _______________________ _____________________________
B. Accountant: _______________________ Address: _____________________________
Telephone: ________________________ _____________________________
C. Insurance Agent: ___________________ Address: _____________________________
Telephone: ________________________ _____________________________
D. Bank: _________________________ Address: _____________________________
Telephone: _______________________ _____________________________
Safe Deposit Box: _________________
9. Special Family Information:
A. Previous marriages and commitments therefrom (attach a copy of decree and settlement papers)
_________________________________________________________________________
10. Life Insurance
A. Company name: Policy #
Owner (H or W) ____ Insured (H or W)
Death benefit $ Cash value $
Beneficiaries: 1st
2nd
B. Company name: Policy #
Owner (H or W) ____Insured (H or W)
Death benefit $ Cash value $
Beneficiaries: 1st
2nd
C. Company name: Policy #
Owner (H or W) ____ Insured (H or W)
Death benefit $ Cash value $
Beneficiaries: 1st
2nd
D. Company name Policy #
Owner (H or W) ____ Insured (H or W)
Death benefit $ Cash value $_______________
Beneficiaries: 1st
2nd
INVENTORY CHECKLIST
(USE FAIR-MARKET VALUE OF ASSETS)
(Round to nearest $100.00 or $1,000.00)
HIS HER JOINT TENANTS
NAME NAME TENANTS COMMON
REAL ESTATE
A. Homestead $____________ $____________ $___________ $ ___________
B. Ag Land Acres ________
County: ____________ ____________ ____________ ___________ ___________
C. Commercial Property
Address: ______________ ____________ ____________ ___________ ___________
D. Rental Property ____________ ____________ ___________ ___________
Address: ______________
E. Vacant Lots ____________ ____________ ___________ ___________
F. Other -- out-of state ____________ ____________ ___________ ___________
Property_______________
PERSONAL PROPERTY
A. Cash $___________ $___________ $___________ $___________
B. Checking Accounts ____________ ____________ ___________ ___________
List bank name & account
numbers on back of Page 3
C. Savings Accounts ____________ ____________ ___________ ___________
List bank name & account
numbers on back of Page 3
D. Certificates of Deposit ____________ ____________ ___________ ___________
List bank name & account
numbers on back of Page 3
E. Bonds/Notes(face amount)
List Issuer & Denominations of
on back of Page 3
(1) Government ____________ ____________ ___________ ___________
(2) Municipal ____________ ____________ ___________ ___________
(3) Corporate ____________ ____________ ___________ ___________
INVENTORY CHECKLIST
HIS HER JOINT TENANTS
NAME NAME TENANTS COMMON
Stocks
(1)Held in Certificate Form
List Company & # of shrs.
on back of Page 3
____________ ____________ ___________ ___________
(2) Held in Brokerage ____________ ____________ ___________ ___________
(attach a copy of most
recent statement)
Mutual Funds ____________ ___________ ____________
(attach a copy of most
recent statement)
H. Non-Qualified Annuities
(not part of a retirement acct.) ____________ ____________
List company name, policy
number and beneficiaries on
back of Page 4
I. Retirement Funds
(1) Traditional IRA ____________ _____________
(2) Roth IRA ____________ _____________
(3) 401(K) ____________ ______________
Name of Company
(4) Pension(s) ____________ ______________
(5) Profit sharing plans ____________ _____________
(6) Qualified Annuities ____________ _____________
(7) Other Retirement
Benefits ____________ _____________
List beneficiaries of each retirement fund on back of Page 4.
J. Business Interests; LLP, LLC, Corp.,
Partnership or Sole Prop.
(1) Cash $____________ $____________ $__________ $___________
(2) Accounts Receivable ____________ ____________ ___________ ___________
(3) Inventory ____________ ____________ ___________ ___________
(4) Equipment ____________ ____________ ___________ ___________
(5) Fixtures ____________ ____________ ___________ ___________
(6) Goodwill ____________ ____________ ___________ ___________
K. Promissory Note/Contract
Receivable ____________ ____________ ___________ ___________
INVENTORY CHECKLIST
HIS HER JOINT TENANTS
NAME NAME TENANTS COMMON
L. Farm Personal Property
(1) Machinery & Equipment ____________ ____________ ___________ ___________
(2) Livestock & Poultry ____________ ____________ ___________ ___________
(3) Growing Crops ____________ ____________ ___________ __________
(4) Grain in storage ____________ ____________ ___________ ___________
M. Miscellaneous
(1) Jewelry, art objects,
collections, furs,
heirlooms, etc. ____________ ____________ ___________
(2) Cars, boats, etc. ____________ ____________ ___________
(3) Furniture & Appliances ____________ ____________ ___________
N. Anticipated Inheritance
Within One Year ____________ ____________
O. Other Assets - list:
(1) _________________ ____________ ____________ ___________ ___________
(2) _________________ ____________ ____________ ___________ ___________
P. Life Insurance
(1) Permanent ____________ ____________
(2) Term ____________ ____________
(3) Group Term ____________ ____________
LIABILITIES
A. Mortgage on home ____________ ____________ ___________ ___________
B. Mortgage on Rental or
Commercial Property ____________ ____________ ___________ ___________
C. R.E. Contract Payable ____________ ____________ ___________ ___________
D. Current Bills ____________ ____________ ___________ ___________
E. Others Debts ____________ ____________ ___________ ___________
H:\BMWord Data\Estate\Estate Planning Information Form.doc
9/25/09
The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for individual advice regarding your own situation. The determination of the need for legal services and the choice of a lawyer are extremely important decisions and should not be based solely upon advertisements or self-proclaimed expertise. All potential clients are urged to make their own independent investigation and evaluation of any lawyer being considered. This disclosure is required by rule of the Supreme Court of Iowa. CV, BV, and AV are registered certification marks of Reed Elsevier Properties Inc., used in accordance with the Martindale-Hubbell certification procedures, standards, and policies.
Copyright © 2010 by Beatty & Miller, P.C. West Des Moines, Iowa. All rights reserved. You may reproduce materials available at this site for your own personal use and for non-commercial distribution. All copies must include this copyright statement.