Estate Planning Worksheet Couple Re: Estate Planning QuestionnaireEnclosed is an Estate Planning Questionnaire for your completion. Please do not worry about total accuracy – just do the best you can.Although you should not spend an inordinate amount of time gathering the information, we have found that having this data available at the initial conference greatly aids both us and the client in focusing on estate planning issues.Of importance is the family information, including the specific ownership of each asset. Although this covers a lot of information, it is necessary to the planning process and, perhaps more importantly, its completion at the outset enables us to keep costs down for you.The financial amounts/values are not necessary before you come in, but we will discuss those in the consultations.Once you complete the form, it will automatically be send it to us at iva@difranzalaw.com. Sincerely yours,DIFRANZA LAW, P.A.Lisa A. DiFranza LAD: tpEnclosuresESTATE PLANNING WORKSHEETPlease return the completed worksheet to us at least three days prior to our meeting (this will ensure we have enough time to understand the specifics of your situation before our meeting). If you need assistance completing the information, call our office (904-372-0216) and we will be glad to help you.PLEASE DON’T WORRY ABOUT TOTAL ACCURACY– JUST DO THE BEST YOU CANIf there is not enough space to enter all the information, please feel free to add a separate sheetWE LOOK FORWARD TO SEEING YOU! ALL INFORMATION PROVIDED IS STRICTLY CONFIDENTIAL. PERSONAL INFORMATIONClient's Name(Print name as you want it to appear in your documents)Birth date MM slash DD slash YYYY SS#US Citizen? Yes NoAddress Home Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home TelephoneCell Phone NumberE-mail It is okay to communicate with me via E-mail. It is okay to communicate with me via E-mail.OccupationEmployerStatus Married Divorced Widowed SingleDate of Marriage YYYY slash MM slash DD Cohabiting CohabitingDomestic Partnership Registration Filed?Prenuptial Agreement? Prenuptial Agreement?Prenuptial Agreement? TextPostnuptial Agreement? Postnuptial Agreement?Postnuptial Agreement? TextIf Divorced, does the order/judgment/settlement agreement restrict your devise of property?CLIENT 2 (SPOUSE/PARTNER) NAME(Print name as you want it to appear in your documents)Birth date MM slash DD slash YYYY SS#US Citizen? Yes NoHome Address Home Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home TelephoneCell Phone NumberE-mail It is okay to communicate with me via E-mail It is okay to communicate with me via E-mailOccupationEmployerStatus Married Divorced Widowed SingleDate of Marriage MM slash DD slash YYYY Cohabiting CohabitingDomestic Partnership Registration Filed?Prenuptial Agreement? Prenuptial Agreement?Prenuptial Agreement? TextPostnuptial Agreement? Postnuptial Agreement?Postnuptial Agreement? TextIf Divorced, does the order/judgment/settlement agreement restrict your devise of property?Children name(s)Date(s) of Birth of ChildrenDESIGNATION INFORMATIONPERSONS TO ACT FOR YOU – IF YOU ARE UNABLE TO ACT FOR YOURSELF DURABLE POWER OF ATTORNEY (decisions re: property, finances): Who do you want making decisions regarding the management of your property?Each spouse/partner for each other? Yes NoWho do you want to make decisions if either of you is unavailable?CLIENT’S SUCCESSOR AGENT(S)Name Address Phone NumberRelationship CLIENT 2’S SUCCESSOR AGENT(S)Name Address Phone NumberRelationship HEALTH CARE DECISION MAKERS If you were unable to make decisions for yourself, who would you want to make decisions for you with regard to your medical treatment?Each spouse/partner for each other? Yes NoWho do you want to make decisions if either of you is unavailable?CLIENT’S SUCCESSOR AGENT(S)Name Address Phone NumberRelationship CLIENT 2’S SUCCESSOR AGENT(S)Name Address Phone NumberRelationship Do you want to be cremated?Do you want to be cremated?Are you an organ donor?Are you an organ donor?Do you want a living will? Yes NoDo you want a living will? Yes NoGUARDIANSHIP If a guardianship is needed, who do you want making decisions regarding the management of your personal and property? (Although the above documents will hopefully eliminate the need for a court supervised guardianship, certain circumstances may require the appointment of a legal guardian. This document will indicate your preference for the court appointment.)Each spouse/partner for each other? Yes NoWho do you want to make decisions if either of you is unavailable?CLIENT’S SUCCESSOR AGENT(S)Name Address Phone NumberRelationship CLIENT 2’S SUCCESSOR AGENT(S)Name Address Phone NumberRelationship PERSONAL REPRESENTATIVE (PR): Who do you want making decisions regarding the management and distribution of your assets to your beneficiaries after you pass? (this is also known as an Executor/Executrix)Each spouse/partner for each other? Yes NoWho do you want to make decisions if either of you is unavailable?CLIENT’S SUCCESSOR PR(S)Name Address Phone NumberRelationship CLIENT 2’S SUCCESSOR PR(S)Name Address Phone NumberRelationship GUARDIAN FOR MINOR CHILDREN (IF APPLICABLE):If you have any children under the age of 18, list in order of preference who would raise them and love them in the manner as close as possible to the way you would. You can name an individual/couple to care for the person and another individual/couple to manage the property/inheritance.Name Address Phone NumberRelationship Successors (if applicable) – if the above named are unable or unwilling to act.Name Address Phone NumberRelationship GUARDIAN FOR PETS (instructions):DISTRIBUTIONS UPON DEATH:Mutual survivorship(each spouse survives the other if simultaneous) Yes NoDistribution will be: To the following OR All to spouse then to those named as follows:Note: If you are creating a trust, distributions will be discussed with the attorney at the meeting.DISTRIBUTIONS UPON DEATHNameParent/RelationshipBirth dateSpecific share in estate If stepchildren, are they to be treated as children of stepparent? Yes NoIf a named individual or charity named above does/do not survive you or exist, who do you want to receive their share? (children of children, other charity, share to be returned to residue to be distributed to surviving beneficiaries, etc.)NameRelationshipBirth dateSpecific share in estate IF APPLICABLE, CHILDREN OR OTHER HEIRS WHO WILL NOT RECEIVE SHARE IN ESTATE:(Use full legal name. For stepparents, note “H” if only husband is the biological parent, note “W” if only wife is the biological parent.)NameParent or Relationship ADVISORSAccountantNameTelephoneFinancial AdvisorNameTelephoneLife Insurance AgentNameTelephoneINCOME/ASSET/LIABILITY INFORMATION ** AMOUNTS/VALUES ARE NOT REQUIRED** Attach additional pages, if necessary.REAL PROPERTY Please list any interest in real estate including your family residence, vacation home, time share or vacant land. (please list manner in which title held – Joint Tenant, Community Property, Separate Property, Tenant in Common)REAL PROPERTYAddressOwner(s) & How Titled * * (Tenants in common, Joint Tenants with Right of Survivorship, Tenancy by the Entireties)PERSONAL PROPERTYTYPE: List separately only major personal effects such as, jewelry, collections, antiques, furs, and all other valuable non-business personal property (indicate type below.).Type or DescriptionOwner BANK & SAVINGS ACCOUNTSTYPE: Checking Account “CA”, Savings Account “SA”, Certificates of Deposit “CD”, Money Market “MM” (indicate type below). Do not include IRA’s or 401(k)’s here Note: If Account is in your name (or your spouse’s name) for the benefit of a minor, please specify and give minor’s name.Name of Institution &Type of AccountOwner(s) STOCKS AND BONDSTYPE: List any and all stocks and bonds you own. If held in a brokerage account, lump them together under each account. (indicate type below)Stocks Bonds or Investment Accounts where held and typeOwner(s) LIFE INSURANCE POLICES AND ANNUITIESTYPE: Term, whole life, split dollar, group life, annuity. ADDITIONAL INFORMATION: Insurance company, type (whole, term, etc.), face amount (death benefit), whose life is insured, who owns the policy, the current beneficiaries, who pays the premium, and who is the life insurance agent.RETIREMENT PLANSTYPE: Pension (P), Profit Sharing (PS), H.R. 10, IRA, SEP, 401(K). ADDITIONAL INFORMATION: Describe the type of plan, the plan name, and any other pertinent information.BUSINESS INTERESTSTYPE: General and Limited Partnerships, Sole Proprietorships, privately owned corporations, professional corporations, oil interests, farm and ranch interests. ADDITIONAL INFORMATION: Give a description of the interests, who has the interest, your ownership in the interests.MONEY OWED TO YOUTYPE: Mortgages or promissory notes payable to you, or other moneys owed to you.Name of DebtorDate of NoteMaturity DateOwed toCurrent Balance ANTICIPATED INHERITANCE, GIFT, OR LAWSUIT JUDGMENTTYPE: Gifts or inheritances that you expect to receive at some time in the future; or moneys that you anticipate receiving through a judgment in a lawsuit. Describe in appropriate detail. DescriptionOTHER ASSETSTYPE: Other property is any property that you have that does not fit into any listed category.TypeOwner CHECKLIST OF ASSETSReal Property Client 1 Client 2Furniture and Personal Effects Client 1 Client 2Bank and Savings Accounts Client 1 Client 2Stocks and Bonds Client 1 Client 2Life Insurance and Annuities Client 1 Client 2Retirement Plans Client 1 Client 2Business Interests Client 1 Client 2Money owed to you Client 1 Client 2Anticipated Inheritance, Etc. Client 1 Client 2Other Assets Client 1 Client 2ADDITIONAL INFORMATION FROM ANYTHING ABOVE OR ANYTHING ELSE YOU BELIEVE TO BE HELPFUL.Δ
