Confidential Information

CONFIDENTIAL INFORMATION

WILL PREPARATION QUESTIONAIRE[1]

NAME: ______TEL. #______

ADDRESS: ______

(Street) (City) (Zip)

MARITAL HISTORY: Present Status (Check one)

______Married

______Single

______Separated

______Divorced and Single

______Divorced and Remarried

Name of present spouse: ______

Prior marriage information, of applicable:

Where married: ______Date ______

(City) (State)

Prior marriage was terminated by: ( ) death ( ) divorce or annulment

Divorce / annulment took place ______

(City) (State)

Date of Court Decree (divorce/annulment) ______

IF YOU WERE PREVIOUSLY DIVORCED OR A MARRIAGE WAS ANNULED, PLEASE BRING IN YOUR COURT DECREE OR DIVORCE JUDGMENT TO YOUR INTAKE SESSION. IF YOU AND YOUR SPOUSE ARE STILL MARRIED BUT LEGALLY SEPARATED, PLEASE BRING IN YOUR COURT DECREE, JUDGMENT, AND ANY SEPARATION AGREEMENT TO YOUR INTAKE SESSION.

PLEASE NOTE: A prior marriage may give another person an interest in your estate. If some aspect of a prior marriage is not clearly indicated above, please explain fully on the other side of this page.

If you were married in any of the following states (community property states) or lived in any of the following states with a spouse, please insert the name of that state below: Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, or Wisconsin:

______

CHILDREN: Include all children, living or deceased, giving their addresses, and giving their married names where appropriate. If born outside of marriage [O] or if adopted [A], please indicate:

NAME BIRTHDATE ADDRESS [O] / [A]

______

GRANDCHILDREN: Include all grandchildren, living or deceased, also giving their parent’s (your child’s) first name. If born outside of marriage [O] or if adopted [A], please indicate:

NAME BIRTHDATE PARENT’S FIRST NAME

______

If any child or grandchild is deceased, give name(s) and dates of birth and death:

______

PARENTS: If deceased, so state; if living, include address.

______

BROTHERS AND SISTERS: If deceased, so state; if living, give married name and address.

______

If brothers and sister are deceased, but have surviving children, give names, ages and addresses of such children:

______

IF YOU, OR YOUR SPOUSE, OR ANOTHER PARTY TO RECEIVE A BENEFIT UNDER YOUR WILL ARE NOT U.S. CITIZENS, THERE MAY BE TAX CONSEQUENCES TO CONSIDER IN PREPARING YOUR WILL. PLEASE INDICATE WHETHER ANY SUCH PARTIES ARE NOT U.S. CITIZENS BY CHECKING THE LINE BELOW. THIS WILL BE DISCUSSED FURTHER WHEN YOU MEET YOUR ATTORNEY:

______One or more persons is NOT a U.S. Citizen.

AT TIMES A PERSON’S HEALTH CONDITIONS OR THE MEDICATIONS THEY ARE TAKING MIGHT IMPAIR THEIR ABILITY TO MAKE A VALID WILL. PLEASE INDICATE WHETHER THIS MAY BE THE CASE BY CHECKING THE APPROPRIATE LINE (OR LINES) BELOW:

______I am current taking (or have been directed to take) prescribed medications.

______I am currently receiving medical care for reasons other than under routine “well care.”

EXPLAIN ANY MEDICAL CONDITIONS AND PLEASE LIST ALL MEDICATIONS AND CONDITIONS BELOW OR ON A SEPARATE PAPER IF THERE IS INSUFFICIENT SPACE BELOW:

______

ASSETS:

NOTE: IF ANY ACCOUNT IS AN IRA, ROTH IRA, or personally held tax deferred retirement account, please indicate such.

BANK ACCOUNTS: Copy exactly as bankbook or statement describes account. DO NOT include full account numbers. If you plan on leaving an account to a particular person, please bring the account’s most recent statement to your initial consultation.

Type of Name of Acct. No. Bank Name & Current

Account Holder LAST 4 DIGITS ONLY Branch Value

______

(If you need more room use reverse side of this sheet.)

LIFE INSURANCE:

For each policy, provide name of insurer, policy value, policy number and date; and the name(s) of each Beneficiary:

1. ______

2. ______

STOCKS AND BONDS:

Name Purchase No. of Price Current Owners

Date Shares Paid Value Name

______

(If you need more room, use reverse side of this sheet)

MUTUAL FUNDS:

Name Current Value Owner

______

HOUSING / REAL ESTATE:

PROPERTY 1: __ Coop Apartment ___ Condominium ____ House ____ Vacant Land

Location Purchase Date Price Paid Current Value

______

Names of All Owners on title:

______

Amount of mortgage at purchase: ______

Remaining mortgage balance today: ______

PROPERTY 2: __ Coop Apartment ___ Condominium ____ House ____ Vacant Land

Location Purchase Date Price Paid Current Value

______

Names of All Owners on title:

______

Amount of mortgage at purchase: ______

Remaining mortgage balance today: ______

NOTE: LIST ALL ADDITIONAL REAL ESTATE PROPERTIES [LOCATED ANYWHERE IN THE WORLD] ON A SEPARATE PAPER.

PERSONAL PROPERTY;

(Items of substance only, such as jewelry, silver, art works, vehicles, coin or stamp collections, musical instruments, etc.)

Item Value

______

RETIREMENT BENEFITS:

Do you have a pension plan [PP]: __ No__ Yes

If yes, what is the current value of your interest? ______

Do you have a deferred compensation plan [DC] or annuity [A] transferrable upon death?

__ No__ Yes

If yes, what is the current value of your interest? ______

Name all listed beneficiaries or substitute beneficiaries on your pension plan [PP], deferred compensation plan [DC] or annuity [A] and indicate the type of plan:

Name Address [PP]/[DC]/ or [A}

______[______]______[______]______[______]

OTHER PROPERTY INTERESTS:

Please list ALL property interests not mentioned above (for example, business or intellectual property rights, trust benefits, litigation settlements, etc.):

______

SALARY AND OTHER INCOME:

Name of Employer, if not city of New York

______

What is your current annual salary? ______

Other income (state source and approximate amounts):

______

DEBTS AND CLAIMS:

Do you have loans or other debts outstanding? ______Yes ______No

Are there any judgments outstanding against you? ______Yes ______No

Are there any lawsuits being brought against or by you against others? ______Yes ____ No

(If yes, give details on the back of this sheet)

LONG TERM CARE INSURANCE: (please list the carrier of any such policy in your name):

______

FUNERAL AND BURIAL PREFERENCES:

Do you need to put any special instructions concerning funeral / burial arrangements in you will? ______Yes ______No

If yes, what are those arrangements: (For Example: interment, cremation, organ donation, etc.)

______

If you have a cemetery plot, give location: ______

______

Before our conference, think about (and jot down if you wish) the answers to the following questions.

1. If you died tomorrow, how would you want your property to be distributed? (Include any specific gifts of property you may wish to leave to any person or persons.)

______

2. If any of the above beneficiaries passes away before you, to whom would you instead leave that gift of property? To that person’s children, siblings, or to someone else?

______

3. If you and your spouse died at the same time, who would you select (as a guardian) to raise any minor children you may have? Who would be your choice for substitute guardian? (Insert Name, Relationship and Address):

______

4. Are any of your planned beneficiaries either mentally or emotionally challenged, disabled, on public assistance, or likely to need public assistance or a supervised distribution of any assets they may receive from you? (Insert Name, Relationship and Address):

______

5. If any beneficiary under your will is not yet an adult, how and when do you want that person’s bequest distributed?

______

6. Upon your death, someone will have to make funeral arrangements, collect your assets, pay your debts and distribute your estate according to your Will. That person is the executor of your estate. The executor is often the primary beneficiary of the Will. What person do you want to name as the executor? Who would be your choice for substitute executor?

(Insert Name, Relationship, and Address for Executor and Substitute (s)):

______

7. If you are also interested in a separate planning document (an advance directive) such as a Living Will/Health Care Proxy discussing how to address your health care decisions in the event of a terminal health condition, please provide the name, address, and phone number of any person (or substitute) you wish to act as your agent.

______

8. If you are also interested in a power of attorney authorizing an agent to act on your behalf to handle your affairs in the event of a disability, please provide the name, address, and phone number of any person (or substitute) you wish to act as your agent / attorney-in-fact.

______

Rev. Dec. 2013

[1] This document, during your lifetime, is NOT subject to third party disclosure as it is shielded by attorney-client privilege. However, should a proceeding arise after your death questioning the validity of your Will, this document would typically be required to be produced as evidence of your intentions and capacity (understanding) before Court of law.