Estate Planning Questionnaire
King & Navins, P.C.
20 Walnut Street, Suite 101
Wellesley, Massachusetts 02481-4102
Telephone: 781-237-0150
Facsimile: 781-237-1165
DATE: ______
1. Family Information
Spouse #1
Name:
Date of birth: SS#: U.S. citizen: Y / N
Address:
Telephone: (home) ( )
(work) ( )
(cell) ( )
Previous Marriages? Y/N
Occupation: ______
E-Mail Address: ______
Siblings Name(s): ______
Living Parents Name(s): ______
Spouse #2
Name: ______
Date of birth: SS#: U.S. citizen: Y / N
Address:
Telephone: (home) ( )
(work) ( )
(cell) ( )
Previous Marriages? Y/N
Occupation: ______
Email address: ______
Siblings Name(s): ______
Living Parents Name(s): ______
Date of marriage: Any pre-marital agreement?______(Please provide a copy)
Child #1
Legal name: Date of birth:
Address:
Spouse:
Grandchildren names and ages:
Child #2
Legal name: Date of birth:
Address:
Spouse:
Grandchildren names and ages:
Child #3
Legal name: Date of birth:
Address:
Spouse:
Grandchildren names and ages:
Child #4
Legal name: Date of birth:
Address:
Spouse:
Grandchildren names and ages:
Special Considerations for children or grandchildren: (prior marriages; special education or health needs; extraordinary financial obligations; spendthrift issues; adoption) ______
______
______
______
______
2. Asset Information
Please list your assets, even if jointly held with another person or in a trust. Please use the following codes to identify whose name is on each asset:
S1 Titled in Spouse #1’s name individually
S2 Titled in Spouse #2’s name individually
JT Titled jointly (between Spouses, unless otherwise indicated)
T Titled in the name of a trust (please specify name of Trust)
Real Estate
(1) Property address:
Title: Mortgage: Current Value:
Year purchased: Purchase price:
Annual taxes: Insurance premium:
Do you have a Declaration of Homestead on your primary residence: Y/N
(2) Property address:
Title: Mortgage: Current Value:
Year purchased: Purchase price:
Annual taxes: Insurance premium:
(3) Property address:
Title: Mortgage: Current Value:
Year purchased: Purchase price:
Annual taxes: Insurance premium:
Bank Accounts
Title Name of bank Type Current value
(1)
(2)
(3)
(4)
(5)
IRAs/401(k)s/other retirement accounts
Owner Name of institution/ Beneficiaries Current value
Type of Acct.
(1)
(2)
(3)
(4)
Stocks/Bonds/ Brokerage Accounts
Title Name of company/brokerage house Current value
(1)
(2)
(3)
(4)
(5)
Life insurance
Insured Name of company Cash surrender Death benefit
(1)
Beneficiaries:
(2)
Beneficiaries:
(3)
Beneficiaries:
(4)
Beneficiaries:
Individual Long Term Care Insurance or Disability Insurance
(1) Name of insurance company______Daily benefit $______
Number of Years______Home Health Benefit? $______Year of Purchase ______
(2) Name of insurance company______Daily benefit $______
Number of Years______Home Health Benefit? $______Year of Purchase ______
Automobiles/boats/motor homes, etc.
Title Year/make/model Loan value Current value
(1)
(2)
(3)
Other Assets
Title Description Current value
(1)
(2)
Have you ever gifted any property in excess of the annual gift tax exclusion to anyone (currently $14,000 per donee per year)? Y/N
If yes, please specify names of beneficiaries, dates & amounts:
Name Date Amount
______
______
______
______
Was a gift tax return filed for any of the above-listed gifts? Y/N
Is either Spouse the beneficiary or trustee of any trust, or does either Spouse anticipate receiving a substantial inheritance? Y/N
If yes, please specify:
______
______
______
______
Is either Spouse named as power of attorney for anyone? Y/N
Income Information
Please list monthly gross income figures.
Spouse #1 Spouse #2 Total
Wages $ $ $
Social Security $ $ $
Pension: $ $ $
Other: ______$ $ $
3. Document Information
LAST WILL & TESTAMENT
Who would Spouse #1 like to nominate as Personal Representative (the individual responsible for managing your estate after death; Spouses usually nominate each other)?
Name: ______
Address (City & State): ______
Who would Spouse #1 like to nominate as alternate Personal Representative, in the event the person named above is unavailable (Spouses usually nominate the same alternate)?
Name: ______
Address (City & State): ______
Who would Spouse #2 like to nominate as Personal Representative?
Name: ______
Address (City & State): ______
Who would Spouse #2 like to nominate as alternate Personal Representative?
Name: ______
Address (City & State): ______
Who would you like to nominate in your Wills as Guardian(s) (the individual(s) who takes care of your children in the event of both Spouses’ death)? Spouses should always nominate the same Guardian(s).
Name: ______
Full Address: ______
Phone Numbers: ______
Who would you like to nominate as alternate Guardian(s), in the event the person named above is unavailable? Spouses should always nominate the same alternate Guardian(s).
Name: ______
Full Address: ______
Phone Numbers: ______
TRUST
Who would you like to appoint as Trustee to oversee the trust established for your minor children in the event of both Spouses’ death? Spouses should appoint the same Trustee.
Name: ______
Address (City & State): ______
Who would you like to appoint as an alternate Trustee, in the event the person named above is unavailable? Spouses should appoint the same alternate Trustee.
Name: ______
Address (City & State): ______
Would you like your spouse to act as sole Trustee of your Trust after your death, or would you like your spouse to act with a co-Trustee? ______
Would you like property to be held in a pooled trust for your children until the youngest reaches a certain age, or would you like their separate shares established immediately after the surviving spouse’s death? ______
Would you like your children’s shares to be distributed outright at a certain age or should the disinterested Trustee decide when to make final distributions? ______
______
Would you like your children, once they reach a certain age, to have any say over who serves as Trustee of their Trust?______
______
In the event you are not survived by any member of your immediate family, who would you like to name as your “backstop” beneficiary/beneficiaries?
Name(s)/Charity:______
______
POWER OF ATTORNEY
Who would Spouse #1 like to appoint as Attorney-in-Fact (the individual to make financial decisions for you in the event that you are incapacitated; Spouses usually appoint each other)?
Name: ______
Address (City & State): ______
Who would Spouse #1 like to appoint as alternate Attorney-in-Fact, in the event the person named above is unavailable (Spouses usually appoint the same alternate)?
Name: ______
Address (City & State): ______
Who would Spouse #2 like to appoint as Attorney-in-Fact?
Name: ______
Address (City & State): ______
Who would Spouse #2 like to appoint as alternate Attorney-in-Fact?
Name: ______
Address (City & State): ______
HEALTH CARE PROXY
Who would Spouse #1 like to appoint as Health Care Agent (the individual to make your health care decisions for you in the event that you are incapacitated; Spouses usually appoint each other)?
Name: ______
Full Address: ______
Phone Numbers: ______
Who would Spouse #1 like to appoint as alternate Health Care Agent, in the event the person named above is unavailable (no need for Spouses to appoint the same alternate)?
Name: ______
Full Address: ______
Phone Numbers: ______
Who would Spouse #2 like to appoint as Health Care Agent?
Name: ______
Full Address: ______
Phone Numbers: ______
Who would Spouse #2 like to appoint as alternate Health Care Agent?
Name: ______
Full Address: ______
Phone Numbers: ______
LIVING WILL
A living will is a set of instructions that memorializes your wishes if you do not want extraordinary life-sustaining measures used in the event you are terminally ill or in an irreversible coma. Although they are not recognized in Massachusetts by statute, living wills are still encouraged because they help instruct your health care proxy agent as to how to carry out your wishes regarding terminal illness.
Would Spouse #1 like to sign a living will? Y/N
Would Spouse #2 like to sign a living will? Y/N
SPECIAL CONCERNS OR PROVISIONS: Please provide any information about concerns you may have or unique provisions you would like placed in your estate planning documents.
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