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)
_________________________________________________________________________
B. Prenuptial Agreements (Attach copy)
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
11. Do you have any frozen sperm, eggs or embryos?
Husband: Yes ( ) or No ( )
Wife: Yes ( ) or No ( )
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 separate page
C. Savings Accounts ____________ ____________ ___________ ___________
List bank name & account
numbers on separate page
D. Certificates of Deposit ____________ ____________ ___________ ___________
List bank name & account
numbers on separate page
INVENTORY CHECKLIST
HIS HER JOINT TENANTS
NAME NAME TENANTS COMMON
E. Bonds/Notes(face amount)
List Issuer & Denominations of
on separate page
(1) Government ____________ ____________ ___________ ___________
(2) Municipal ____________ ____________ ___________ ___________
(3) Corporate ____________ ____________ ___________ ___________
F. Stocks
(1)Held in Certificate Form
List Company & # of shrs.
on separate page
____________ ____________ ___________ ___________
(2) Held in Brokerage ____________ ____________ ___________ ___________
(attach a copy of most
recent statement)
G. 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
separate page
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 separate page.
INVENTORY CHECKLIST
HIS HER JOINT TENANTS
NAME NAME TENANTS COMMON
J. Business Interests; LLP, LLC, Corp.,
Partnership or Sole Proprietership
(1) Cash $____________ $____________ $__________ $___________
(2) Accounts Receivable ____________ ____________ ___________ ___________
(3) Inventory ____________ ____________ ___________ ___________
(4) Equipment ____________ ____________ ___________ ___________
(5) Fixtures ____________ ____________ ___________ ___________
(6) Goodwill ____________ ____________ ___________ ___________
K. Promissory Note/Contract
Receivable ____________ ____________ ___________ ___________
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 ____________ ____________
INVENTORY CHECKLIST
HIS HER JOINT TENANTS
NAME NAME TENANTS COMMON
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
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