ESTATE AND TAX PLANNING QUESTIONNAIRE

Briefly describe what you would like to accomplish at this conference?

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FAMILY INFORMATION (Please use full names)

Husband / Wife
Name
Usual Way of Signing
Date of Birth
Citizenship
Email Address
Work Telephone
Cell Telephone

HOME ADDRESS

Street or PO Box
City, State and Zip Code
Home Telephone
Date/Place of Marriage

CHILDREN OF THIS MARRIAGE (include information for spouses of married children)

Name / Address / Date of Birth

DECEASED CHILDREN, if any

FAMILY CIRCUMSTANCES: Note, any special family considerations (i.e. previous marriages, special health problems of any family members; if spouse is deceased, please state date of death):

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PRIOR MARRIAGES (name of prior spouse and how terminated)

Husband
Wife

CHILDRED FROM PRIOR MARRIAGE (include information for spouses of married children)

NAME / ADDRESS / DATE OF BIRTH

If you have any minor children please state whether any such child has separate assets (such as custodial accounts, including approximate amounts and in whose name they are held):

YOUR LIVING PARENTS AND STEPPARENTS

HUSBAND:

Name / Address / Telephone Number

WIFE:

Name / Address / Telephone Number

YOUR LIVING BROTHERS/SISTERS AND STEPBROTHERS/STEPSISTERS

HUSBAND:

Name / Address / Telephone Number

WIFE:

Name / Address / Telephone Number

INCOME/EMPLOYMENT

Husband / Wife
Occupation
Salary
Net Rental Income
Dividends/Interest
Pension
Social Security
Other (explain)

REAL ESTATE-PRINCIPAL RESIDENCE:

Location
Name(s) on Deed
Tax Assessed Value
Fair Market Value (estimated)
Date Purchased
Purchase Price
Remaining Mortgage
Other Liens on the Property

REAL ESTATE-OTHER:

Location
Name(s) on Deed
Tax Assessed Value
Fair Market Value (estimated)
Date Purchased
Purchase Price
Remaining Mortgage
Other Liens on the Property

REAL ESTATE-OTHER:

Location
Name(s) on Deed
Tax Assessed Value
Fair Market Value (estimated)
Date Purchased
Purchase Price
Remaining Mortgage
Other Liens on the Property

CHECKING ACCOUNTS:

Bank / Balance / Name(s) on

SAVINGS ACCOUNTS:

Bank / Balance / Name(s) on

OTHER BANK ASSETS:

Bank / Type of Account / Balance / Name(s) on

LISTED SECURITIES (READILY SALABLE)

Company / # of Shares / Name(s) on Certificate / Approximate Value

IRA, 401k and OTHER RETIREMENT ACCOUNTS:

Financial Institution / Type of Account / Balance / Participant/Beneficiary

BUSINESS INTERESTS (OWNED BY HUSBAND OR WIFE):

If either of you owns any interest in a closely-held business, attach a statement indicating: 1. Type of business; 2. Form of business (e.g., corporation, partnership, of sole proprietorship); 3. Your share of the business; 4.Your position in the business; 5.Other owners, their shares and relationship to you; 6. Whether there is a buy/sell agreement; and 7. Desired disposition of your share.

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LIFE INSURANCE:

Policy 1:

Company Name
Type of Policy
Owner of Policy
Insured
Death Benefit
Cash Value
Beneficiary(ies)

Policy 2:

Company Name
Type of Policy
Owner of Policy
Insured
Death Benefit
Cash Value
Beneficiary(ies)

Policy 3:

Company Name
Type of Policy
Owner of Policy
Insured
Death Benefit
Cash Value
Beneficiary(ies)

LONG TERM CARE INSURANCE:

Company Name
Person Insured
Daily Benefit Amount
Elimination Term
Elimination Period

MISCELLANEOUS:

Indicate expected inheritances; valuable personal property; promissory notes payable to you; or any special factors that may affect your situation.

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PRIOR GIFTS:

Itemize past gifts over $14,000/year you made to any one individual (or irrevocable trust); indicate whether you filed a gift tax return.

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LIABILITIES:

Indicate significant debts and debts guaranteed by you (excluding mortgages listed earlier), as well as law suits, or claims, present or anticipated.

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SAFE DEPOSIT BOX:

Location and persons having access:

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YOUR PROFESSIONAL ADVISORS

Name / Firm / Telephone
Accountant
Attorney
Insurance Advisor
Financial Planner
Stockbroker
Other

PLEASE INDICATE HOW YOU WERE REFERRED TO OUR FIRM:

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Please note any additional comments, information, or specific questions you wish to have answered.

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