ESTATE PLANNING QUESTIONNAIRE Jared S. Olsen ep Estate Planner jared@olsenlegalgroup.com www.olsenlegalgroup.com
I. Personal Information for Client (Please PRINT clearly) Full Legal Name (List additional names, or variations of names, that you have used or owned property under) Citizenship Social Security No. Place of Birth Date of Birth Home Address County of Residence Home Phone Cell Phone Email Occupation Employer/Business Address Business Phone Business Email Preferred Email? Fax Number Status of Health Insurable? Marital Status Home Business Other: Married Date of Marriage Divorced Single (If divorced, please provide a copy of the Separation Agreement.) II. Personal Information for Client s Spouse (Please PRINT clearly) Full Legal Name (List additional names, or variations of names, that you have used or owned property under) Citizenship Social Security No. Page 1 of 9
Place of Birth Date of Birth Home Address County of Residence Home Phone Cell Phone Email Occupation Employer/Business Address Business Phone Business Email Preferred Email? Home Business Other: Fax Number Status of Health Insurable? Previously Married? (If divorced, please provide a copy of the Separation Agreement.) III. Objectives and Goals Please briefly discuss what you would like to accomplish as part of this process. You may want to include in your discussion thoughts about the following issues as well as other issues important to you: Asset protection for children and descendants Estate and gift tax planning Intergenerational planning Simplification of estate administration Charitable objectives Page 2 of 9
IV. Children / Grandchildren Children Full Legal Name Address Date of Birth (or note Date of Death if deceased) Marital Status Grandchildren Please use additional pages as necessary. Page 3 of 9
Other Beneficiaries Please use additional pages as necessary. V. Parents, Brothers and Sisters Use additional pages as necessary. If any relative is deceased, please write Deceased in. A. Parents Mother: Full Legal Name Father: Full Legal Name B. Brothers and Sisters 1. Full Legal Name 2. Full Legal Name 3. Full Legal Name 4. Full Legal Name Page 4 of 9
5. Full Legal Name C. Other Dependents. Are any persons other than minor children dependent on you? If so, describe relationship and degree of dependency: V. Assets / Liabilities / Income ASSETS (List current full value, disregarding any debt or liabilities attached to asset, and state how the property is held.) 1. Checking (do not include retirement assets, such as IRAs; note those later in Item 6, below) Description Value How is the Asset Titled? My Name Only Tenants by the Entirety My Name Only Tenants by the Entirety 2. Savings (do not include retirement assets, such as IRAs; note those later in Item 6, below) Description Value How is the Asset Titled? My Name Only Tenants by the Entirety My Name Only Tenants by the Entirety 3. CD s, Stocks & Bonds, and Other Securities (do not include retirement assets, such as IRAs; note those later in Item 6, below) Description Value How is the Asset Titled? My Name Only Tenants by the Entirety My Name Only Tenants by the Entirety My Name Only Tenants by the Entirety Page 5 of 9
4. Real Property (current fair market value of real property ignore any mortgage; enter that in Liabilities, below) Description Value/Equity How is the Asset Titled? Residence $ My Name Only Tenants by the Entirety Other $ My Name Only Tenants by the Entirety Check if any real property is not located in MyState. 5. Tangible Personal Property (total fair market value of jewelry, antiques, art objects, household furnishings, auto-mobiles, boats, airplanes, hobby collections, etc.) Description Value How are the Assets Titled? My Name Only Tenants by the Entirety My Name Only Tenants by the Entirety My Name Only Tenants by the Entirety My Name Only Tenants by the Entirety My Name Only Tenants by the Entirety Tenants in Common Joint Tenancy My Name Only Tenants by the Entirety 6. Closely held Business Interests (approximate value of any business interests) Description Value How is the Asset Titled? My Name Only Tenants by the Entirety Describe, briefly, the Business Interests (name, how organized, etc.): Page 6 of 9
7. Life Insurance (Enter the following information for each life insurance policy, including Group Plans) Name of Insurance Company Type: (T)erm, (W)hole Life, (O)ther Insured's Name Owner of Policy $ Amount of Death Benefit Beneficiary Name(s) (Copy this section as necessary for additional insurance policies) 8. Retirement Plans (Current value of retirement / employee benefit plans, including IRAs, 401(k)s, pension, profit sharing, etc., and the primary and contingent beneficiaries of each. Attach additional pages as necessary) IRA (Traditional) Primary Beneficiary: Contingent Beneficiary: IRA (Roth) Primary Beneficiary: Contingent Beneficiary: 401(k) (Regular) Primary Beneficiary: Contingent Beneficiary: 401(k) (Roth) Primary Beneficiary: Contingent Beneficiary: Other Plan Primary Beneficiary: Contingent Beneficiary: Page 7 of 9
9. Other Assets (Describe any other assets in which you may have an interest that has not otherwise been included in this Questionnaire. For example, intangible personal property (patents, licenses, etc.), deferred compensation plans, transferable club memberships, royalty rights, etc.) 1. Credit Cards 2. Mortgage on: Residence Other Real Estate 3. Notes Payable 4. Other liabilities not shown above (please describe) 1. Employment 2. Other LIABILITIES INCOME Special Situations. Please check if any of the following apply to you: Party to a buy-sell agreement Party to a lawsuit Outstanding obligations under divorce decree Making payments pursuant to a divorce of property order Have a special needs for you, child, or other dependent I am storing, or may store, frozen eggs, sperm or embryos Signed a pre/post marriage contract Own a business Own long-term care (nursing home) insurance policy Have filed federal or state gift tax returns Support any charitable organizations now or in the future Currently the beneficiary of someone else s trust/will Page 8 of 9
Existing Documents. Do you currently have any of the following instruments? (check all that apply) Will (Year State ) Power of Attorney for Property (Year State ) Power of Attorney for Health Care (Year State ) Final Arrangements Representative Living Will (Advance Health Care) (Year State ) Living/Revocable Trust (Year State ) Divorce/Separation Agreement (Year State ) If available, please provide a copy of any of the above documents, as well as any Trust Agreements of any trusts in which you may have an interest (as beneficiary, trustee, power to appoint assets, etc.) to me. Page 9 of 9