HILL, ULLMAN & ERWIN, P.C.

Attorneys at Law

NEW YORK | WATER MILL | SCARSDALE

Scarsdale, NY 825 Third Avenue Water Mill, NY

914.725.2180 New York, NY 10022-9524 631.726.1922

212.682.3366 • fax 212.682.3367

ESTATE PLANNING QUESTIONNAIRE

All Information You Provide Will be Considered Personal and Confidential

Date:______

CLIENTS' NAMES: ______

Home Address: ______

______

Home Phone: Home Fax: ______

Name: ______Name: ______

Business or Profession : Business or Profession : ______

Business Phone : Business Phone: :

Cell Phone : Cell Phone:

Business Fax : Business Fax : ______

Email : Email : ______

Date of Birth: Date of Birth: ______

Social Security Number: Social Security Number: ______

Citizenship: Citizenship: ______

Children's Name Date of Birth Social Security Number

______

______

______

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______

Identify Any Children From A Prior Relationship

4

Name Date of Birth Social Security Number

______

______

______

How Many Grandchildren?

Name Date of Birth Social Security Number

______

______

______

______

______

______

Prenuptial Agreement? ______Divorce From Prior Spouse? ______

Settlement Agreement? ______Court Order?______

Child Support? ______Alimony? ______

Gifts:

Amount of Any Gifts Made by You to Your Children or Others:

Husband Wife

(A) in Excess of $3,000 prior to 1982? ______

(B) in Excess of $10,000 after 1982 and before 2002? ______

(C) in Excess of $11,000 after 2002 and before 2006? ______

(D) in Excess of $12,000 after 2006 and before 2009? ______

(E) in Excess of $13,000 after 2009 and before 2012? ______

(F) in Excess of $14,000 after 2013? ______

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Name / Telephone Number
Accountant:
Investment Manager:
Insurance Agent:

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SUMMARY OF ASSETS & LIABILITIES

ASSETS / APPROX.
FAIR MARKET VALUE / MORTGAGE
OR OTHER
LIABILITY / NET VALUE / BASIS / HOW IS
TITLE HELD? (H/W/Joint) /
RESIDENCE
SECOND RESIDENCE
OTHER REAL ESTATE & LOCATION
OTHER REAL ESTATE & LOCATION
STOCKS & BONDS
BUSINESS INTERESTS
CASH IN BANK
NOTES RECEIVABLE
COLLECTIBLES
(COINS, ART, ANTIQUES, ETC.)
OTHER PERSONAL PROPERTY
RETIREMENT PLAN ASSETS
OTHER ASSETS
LIFE INSURANCE POLICIES / INSURED / OWNER / BENEFICIARY / FACE AMOUNT / VALUE OF PERMANENT POLICY

LIABILITIES

NET WORTH
(ASSETS LESS LIABILITIES)

Do you currently have the following documents? Please circle Yes or No:

Y N Last Will and Testament

Y N Revocable Trust/ Pourover Will

Y N Power of Attorney

Y N Health Care Proxy

Y N Beneficiary Designations

Y N Nomination of Guardian of Self

Y N Nomination of Guardian of Child

Y N Burial Instructions

Y N Irrevocable Life Insurance Trust

Y N Irrevocable Trust for life time gifts

Y N Qualified Personal Residence Trust

Y N Grantor Retained Annuity Trust

Y N Charitable Remainder Trust

Y N Charitable Lead Trust

Y N Power of Appointment

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