LAW OFFICE OF PATRICIA E. TICHENOR, P.L.L.C.

19490 Sandridge Way, Suite 370A

Leesburg, Virginia 20176

(703) 669-6700 Telephone

(703) 669-6701 Facsimile

Email: OR

Estate Planning Questionnaire (Single Person)

TODAY’S DATE

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How did you hear about our firm? Click here to enter text.

Do you prefer to receive DRAFTS by e-mail? Click here to enter text.

  1. CLIENT:

Full Name: Click here to enter text.

Date of Birth: Click here to enter a date.

Social Security Number: Click here to enter text.

Marital Status:

☐ Single

☐ Married

☐ Divorced

☐ Separated

☐ Widowed

Total No. of Marriages: Click here to enter text.

If you indicated you have any marriages, please provide the name of the spouse, and if applicable the date of divorce from previous spouse(s) along with the city, state divorce was granted in. Click here to enter text.

If widowed, please provide:

Full Name of Spouse: Click here to enter text.

Date of Death: Click here to enter text.

  1. ADDRESS

Click here to enter text.(street address) Click here to enter text. (city)

Click here to enter text. (state)Click here to enter text.(zip)

  1. PHONE NUMBERS

Home Phone Number Click here to enter text.

Mobile Phone Number Click here to enter text.

WorkPhone Number Click here to enter text.

Email Address: Click here to enter text.

Employer: Click here to enter text.

Employer Address: Click here to enter text.

  1. Do you hold a Power of Appointment ☐ Yes ☐ No
  1. Are you a Beneficiary of a Trust ☐ Yes ☐ No
  1. If married, do you and your spouse have a premarital/prenuptial agreement?

☐ Yes ☐ No

  1. APPROXIMATENET WORTH OF ASSETS

Approximate Worth of Retirement Accounts Click here to enter text.

Approximate Worth of Life Insurance Click here to enter text.

Approximate Worth of Real Property Click here to enter text.

Approximate Net Worth of All Other Assets (checking/savings/stocks, etc)

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  1. INFORMATION REGARDING CHILDREN (adult, minors, adopted):

Name / Address / Date of Birth / Telephone Nos. / Marital Status / Name of other Parent if not Current Spouse / # of Children
They Have
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Home Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
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Home Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
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Home Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
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Home Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
  1. Additional Information Regarding Family Members

(Only provide the below information if family member is still alive)

Father’s Name Click here to enter text.
Father’s Address Click here to enter text.
Father’s Home Number Click here to enter text.
Father’s Mobile Number Click here to enter text. / Mother’s Name Click here to enter text.
Mother’s Address Click here to enter text.
Mother’s Home Number Click here to enter text.
Mother’s Mobile Number Click here to enter text.
Name of Sibling #1 Click here to enter text.
Sibling #1 Address Click here to enter text.
Sibling #1 Home Number Click here to enter text.
Sibling #1 Mobile Number Click here to enter text. / Name of Sibling #2 Click here to enter text.
Sibling #2 Address Click here to enter text.
Sibling #2 Home Number Click here to enter text.
Sibling #2 Mobile Number Click here to enter text.
Name of Sibling #3 Click here to enter text.
Sibling #3 Address Click here to enter text.
Sibling #3 Home Number Click here to enter text.
Sibling #3 Mobile Number Click here to enter text. / Name of Sibling #4 Click here to enter text.
Sibling #4 Address Click here to enter text.
Sibling #4 Home Number Click here to enter text.
Sibling #4 Mobile Number Click here to enter text.
  1. INFORMATION ABOUT FIDUCIARIES

Executor: After your death, your executor will be responsible for probating your Will, collecting the assets of your estate, carrying out the directions contained in your Will, filing income tax returns for you and your estate, filing estate tax returns for your estate and accounting (to the penny) to the Court for all of the assets passing through the executor’s hands.

Trustee: Your Trustee will be responsible for investing the assets of the trust, distributing the income and principal of the trust to the beneficiaries during the term of the trust, filing income tax returns for the trust, accounting to the beneficiaries each year and distributing all of the trust assets when it terminates.

Guardian: The guardian of a minor (under age 18) becomes the substitute parent of the child and normally the child will live with the guardian. The guardian does not have control over the assets given to the child (unless you name your guardian trustee OR unless you have not created a trust in your Will). If there is no trust, the guardian will have control over those assets, but only until the child reaches either age 18 or 21

Agent/Attorney-in-Fact (Financial POA): The agent named in your Durable General (Financial) Power of Attorney has the power to conduct your financial affairs on your behalf.

Agent/Attorney-in-Fact (Medical POA): The agent named in your Durable Medical Power of Attorney, beginning at the time you are unable to make health care decisions for yourself (i.e. you become incapacitated in some way) will make health care decisions for you.

  1. INFORMATION REGARDING EXECUTORS

Please indicate who you wish to name executor of your Will. During the consultation we will go over this again, and you may change your executor and/or add another alternate if you choose to do so.

Executor #1 Name Click here to enter text.
Address Click here to enter text.
Home Number Click here to enter text.
Mobile Number Click here to enter text.
Relationship to you Click here to enter text.
Date of Birth Click here to enter a date. / Alternate Executor #2 Name Click here to enter text.
Address Click here to enter text.
Home Number Click here to enter text.
Mobile Number Click here to enter text.
Relationship to you Click here to enter text.
Date of Birth Click here to enter a date. / Alternate Executor #3 Name Click here to enter text.
Address Click here to enter text.
Home Number Click here to enter text.
Mobile Number Click here to enter text.
Relationship to you Click here to enter text.
Date of Birth Click here to enter a date.
  1. INFORMATION REGARDING TRUSTEES

If you have minor children or minor grandchildren and desire to have Trustee provisions within your Will OR if you are having us draft a TRUST for you instead of a Will, please provide the following information for desired Trustees.

Please Note: If you are married, your spouse can not be named Trustee.

Trustee #1Name Click here to enter text.
Address Click here to enter text.
Home Number Click here to enter text.
Mobile Number Click here to enter text.
Relationship to you Click here to enter text.
Date of Birth Click here to enter a date. / Trustee #2 Name Click here to enter text.
Address Click here to enter text.
Home Number Click here to enter text.
Mobile Number Click here to enter text.
Relationship to you Click here to enter text.
Date of Birth Click here to enter a date. / Trustee #3 Name Click here to enter text.
Address Click here to enter text.
Home Number Click here to enter text.
Mobile Number Click here to enter text.
Relationship to you Click here to enter text.
Date of Birth Click here to enter a date.
  1. INFORMATION REGARDING GUARDIANS

Please indicate who you would like to designate as Guardian of your Children in the event that you are no longer living.

***IF the child’s other parent is still alive, he/she has to be named as first Guardian so provide her/his information under Guardian #1****

Guardian #1 Name
Click here to enter text.
Address Click here to enter text.
Home Number Click here to enter text.
Mobile Number Click here to enter text.
Relationship to you Click here to enter text.
Date of Birth Click here to enter a date. / Guardian #2 Name
Click here to enter text.
Address Click here to enter text.
Home Number Click here to enter text.
Mobile Number Click here to enter text.
Relationship to you Click here to enter text.
Date of Birth Click here to enter a date. / Guardian #3 Name
Click here to enter text.
Address Click here to enter text.
Home Number Click here to enter text.
Mobile Number Click here to enter text.
Relationship to you Click here to enter text.
Date of Birth Click here to enter a date.
  1. DISTRIBUTION OF ESTATE IN LAST WILL & TESTAMENT

Please explain how you would you like your Estate distributed and who you desire to name as beneficiaries:

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  1. INFORMATION FOR DURABLE GENERAL (FINANCIAL) POWER OF ATTORNEY

Agent #1 Name Click here to enter text.
Address Click here to enter text.
Home Number Click here to enter text.
Mobile Number Click here to enter text.
Relationship to you Click here to enter text.
Date of Birth Click here to enter a date. / Alternate Agent #2 Name Click here to enter text.
Address Click here to enter text.
Home Number Click here to enter text.
Mobile Number Click here to enter text.
Relationship to you Click here to enter text.
Date of Birth Click here to enter a date. / Alternate Agent #3 Name Click here to enter text.
Address Click here to enter text.
Home Number Click here to enter text.
Mobile Number Click here to enter text.
Relationship to you Click here to enter text.
Date of Birth Click here to enter a date.
  1. INFORMATION FOR DURABLE MEDICAL POWER OF ATTORNEY

If you desire to name the same agents as you have for your Durable General Power of Attorney (above), please check here ☐

Agent #1 Name Click here to enter text.
Address Click here to enter text.
Home Number Click here to enter text.
Mobile Number Click here to enter text.
Relationship to you Click here to enter text.
Date of Birth Click here to enter a date. / Alternate Agent #2 Name Click here to enter text.
Address Click here to enter text.
Home Number Click here to enter text.
Mobile Number Click here to enter text.
Relationship to you Click here to enter text.
Date of BirthClick here to enter a date. / Alternate Agent #3 Name Click here to enter text.
Address Click here to enter text.
Home Number Click here to enter text.
Mobile Number Click here to enter text.
Relationship to you Click here to enter text.
Date of Birth Click here to enter a date.

Additional Information for Medical POA

Organ Donor ☐ Yes ☐ No

Wishes for Disposition of Body Click here to enter text.

Primary Physician Name Click here to enter text. Type of Doctor Click here to enter text.

Affiliated with Click here to enter text.

Address Click here to enter text. Telephone Number Click here to enter text.

If you receive medical care from any specialists, please provide

Specialist Name Click here to enter text. Type of Doctor Click here to enter text.

Affiliated with Click here to enter text.

Address Click here to enter text. Telephone Number Click here to enter text.

Health Insurance Information

Type of Insurance Click here to enter text. Identification No. Click here to enter text.

Group No. Click here to enter text.

Mailing Address (found on back of card, usually P.O. Box) Click here to enter text.

Telephone Number Click here to enter text.

Medicare ☐ Yes ☐ No

Is Medicare your Primary ☐ Yes ☐ NO

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