ESTATE PLANNING QUESTIONNAIRE Please complete all applicable portions of the following questionnaire. Please note that if you cannot complete the questionnaire in one sitting, the form will save your answers for you. Would you like to create a Single Trust for yourself or a Couples Trust with your spouse or partner?* Single Trust Couples Trust Your InformationFirst Name*Middle NameLast Name*Enter your name as it appears on your State Drivers License or Identification Card. Gender: Male Female Marital Status:* Single, Never Divorced Single, Previously Divorced Married, Never Divorced Married, Previously Divorced Registered Domestic Partners Date of Current Marriage or Domestic Partnership: Spouse/Partner InformationSpouse/Partner First Name*Spouse/Partner Middle NameSpouse/Partner Last NameEnter your name as it appears on your State Drivers License or Identification Card. Spouse/Partner's Gender: Male Female Spouse/Partner Marital Status:* Single, Never Divorced Single, Previously Divorced Married, Never Divorced Married, Previously Divorced Registered Domestic Partners Contact InformationPhone*Email* If you do not have an email address please enter NONE@NONE.com.Street Address*City*State*Zip Code* Trust InformationWhat would you like the name of your Trust to be?*The name of your Trust can be anything you would like, please enter the name exactly as you would like it to appear.Do you wish for your trustees to be successor trustees or co-trustees?* Successor Trustees Co-Trustees We recommend Successor Trustees. If you choose Successor only one person will be in control of your Trust at anytime however if you choose Co multiple persons will be in control at the same time.Who would you like to designate as trustees of your Trust after you have passed:Name:Relationship:Address:Phone: These are the persons who will be in charge of your Trust after you pass. We recommend selecting 3 trustees to plan for the event that one is not able to act. For "Relationship" please include the proper pronoun as well, for example "my sister" or "our friend". Click the + on the right to add additional trustees.Would you like the trustees you designated to also act as your agents for financial affiars and medical decisions?* Yes No Do you have children?* Yes No Do you or your spouse/partner have any children:* No. Yes, Children together. Yes, I have children from a prior relationship. Yes, my spouse/partner has children from a prior relationship. Please choose as many as are applicable. Children's InformationChildren:Name:Date of Birth: Click the + on the right to add additional children.Your Children from a prior relationship:Name:Date of Birth: Click the + on the right to add additional children.Your spouse/partner's Children from a prior relationship:Name:Date of Birth: Click the + on the right to add additional children. Financial Power of Attorney InformationWould you like your spouse/partner to be your initial agent for your financial affairs?* Yes No Do you wish for your agents for financial affairs to be successor agents or co-agents?* Successor Agents Co-Agents We recommend Successor Agents. If you choose Successor only one person will be in control of your Finances at anytime however if you choose Co multiple persons will be in control at the same time.Who would you like to designate to control your financial affairs in the event of your incapacitation?Name:Relationship:Address:Phone: We recommend selecting 3 agents to plan for the event that one is not able to act. For "Relationship" please include the proper pronoun as well, for example "my sister" or "our friend". Click the + on the right to add additional agents.If your spouse is an agent for your financial affairs would you like their powers to be immediate?* Yes No If you answer "No" your spouse will only have power in the event you are incapacitated. Would you like your agents to have immediate power over your finances?* Yes No If you answer "No" your agents will only have power in the event you are incapacitated. Would you like to grant your financial agents the power to create an irrevocable trust?* Yes No This would allow your agents to create an irrevocable trust upon your incapacitation, you would not have the power to change this if it occurred.Would you like to grant your financial agents the power to gift?* Yes No This would allow your agents to give unlimited amounts of gifts in the event of your incapacitation. Medical Power of Attorney InformationWould you like your spouse/partner to be your initial agent for your medical affairs?* Yes No Do you wish for your agents for medical decisions to be successor agents or co-agents?* Successor Agents Co-Agents We recommend Successor Agents. If you choose Successor only one person will be in control of your Medical Decisions at anytime however if you choose Co multiple persons will be in control at the same time.Who would you like to designate to control your medical decisions in the event you are incapacitated?Name:Relationsip:Address:Phone: We recommend selecting 3 agents to plan for the event that one is not able to act. For "Relationship" please include the proper pronoun as well, for example "my sister" or "our friend". Click the + on the right to add additional agents.If you are terminally ill do you prefer to die naturally without the use of extraordinary measures?* Yes No If you answer "No" then you would prefer the use of artificial means of respiration and nutrition to extend your life.If you are ever in an irreversable coma, persistent vegitative state, or in the advanced stages of alzheimer's or senility do you wish for extraordinary measures to be taken to extend your life?* Yes No If you are terminally ill and are diagnosed with a second terminal illness do you wish to treat the second illness?* Yes No Do you wish to be relieved from pain even if the means of pain relief may hasten your death?* Yes No If withholding food and water causes you pain but extends your life do you want food and water withheld?* Yes No Final Disposition InstructionsWould you prefer to be Buried or Cremated?* Buried Cremated Do you have specific instructions for your remains after passing?* Yes No Please describe any post-death arrangements you have made or your final wishes for your remains. Spouse/Partner's Power of Attorney InformationWould you like your agents for financial affairs to be the same as your spouse/partner has selected?* Yes No Would you like your agents for medical decisions to be the same as your spouse/partner has selected?* Yes No Spouse/Partner's Financial Power of Attorney InformationWould you like your spouse/partner to be your initial agent for your financial affairs?* Yes No Do you wish for your agents for financial affairs to be successor agents or co-agents?* Successor Agents Co-Agents We recommend Successor Agents. If you choose Successor only one person will be in control of your Finances at anytime however if you choose Co multiple persons will be in control at the same time.Who would you like to designate to control your financial affiars in the event you are incapacitated?Name:Relationship:Address:Phone: We recommend selecting 3 agents to plan for the event that one is not able to act. For "Relationship" please include the proper pronoun as well, for example "my sister" or "our friend". Click the + on the right to add additional agents.If your spouse is an agent for your financial affairs would you like their powers to be immediate?* Yes No If you answer "No" your spouse will only have power in the event you are incapacitated. Would you like your agents to have immediate power over your finances?* Yes No If you answer "No" your agents will only have power in the event you are incapacitated. Would you like to grant your financial agents the power to create an irrevocable trust?* Yes No This would allow your agents to create an irrevocable trust upon your incapacitation, you would not have the power to change this if it occurred.Would you like to grant your financial agents the power to gift?* Yes No This would allow your agents to give unlimited amounts of gifts in the event of your incapacitation. Spouse/Partner's Medical Power of Attorney InformationWould you like your spouse/partner to be your initial agent for your medical decisions?* Yes No Do you wish for your agents for medical decisions to be successor agents or co-agents?* Successor Agents Co-Agents We recommend Successor Agents. If you choose Successor only one person will be in control of your Medical Decisions at anytime however if you choose Co multiple persons will be in control at the same time.Who would you like to designate to control your medical decisions in the event you are incapacitated?Name:Relationship:Address:Phone: We recommend selecting 3 agents to plan for the event that one is not able to act. For "Relationship" please include the proper pronoun as well, for example "my sister" or "our friend". Click the + on the right to add additional agents.If you are terminally ill do you prefer to die naturally without the use of extraordinary measures?* Yes No If you are ever in an irreversable coma, persistent vegitative state, or in the advanced stages of alzheimer's or senility do you wish for extraordinary measures to be taken to extend your life?* Yes No If you are terminally ill and are diagnosed with a second terminal illness do you wish to treat the second illness?* Yes No Do you wish to be relieved from pain even if the means of pain relief may hasten your death?* Yes No If withholding food and water causes you pain but extends your life do you want food and water withheld?* Yes No Spouse/Partner's Final Disposition InstructionsWould you prefer to be Buried or Cremated?* Buried Cremated Do you have specific instructions for your remains after passing?* Yes No Please describe any post-death arrangements you have made or your final wishes for your remains. Trust Assets and FundingType of assets you would like to put in your Trust: Real Estate Bank Accounts Brokerage Accounts, Mutual Funds or IRAs Stock or Bond Certificates Sole Proprietorships, Partnership Interests or Business Interests Other Significant Property (Cars, Jewelry, Collectibles, Inheritance Rights, Household Furnishings, Cash, etc.) Estimate of Gross Value of your entire Estate:This value should represent the total value of all your assets regardless of debts. Real Estate InformationClick the + on the right to add additional real estate.Street AddressCityStateZip Code Click the + on the right to add additional real estate. Bank Account InformationClick the + on the right to add additional bank accounts.Name of Bank:Type of Account:Account Number: Click the + on the right to add additional bank accounts. Investment Account InformationClick the + on the right to add additional investment accounts.Name of Bank:Type of Account:Account Number: Click the + on the right to add additional investment accounts. Stock and Bond InformationClick the + on the right to add additional stocks or bonds.Name of Stock or Certificates:Cerftificate/Share Numbers Click the + on the right to add additional stocks or bonds. Business Interests InformationClick the + on the right to add additional business interests.Name of Businness or Partnership:Type of Business Interest or Partnership:Percent Ownership: Click the + on the right to add additional business interests. Additional Asset InformationClick the + on the right to add additional assets.Description:Estimated Value: Click the + on the right to add additional assets. Distribution of EstateWould you like to make any specific gifts to individuals or groups?* Yes No For example a specific piece or real-estate to a specific person, a cash gift of a specific amount to a charity, a cash gift of a specific amount to a person.Click the + on the right to add additional assets.Name of Recipient:Description or Amount of Gift: Click the + on the right to add additional assets.Not including, if any, the specific gifts you outlined above think of all of your assets as 100% of your Estate. Please outline below how you would like to distribute your estate. For example 50% to John, 25% to Jane and 25% to Charity. Please note the total of your percentages should add to 100%.Name of Recipient:Relationship of Recipient:Recipient Addess:Recipient Phone:Percent of Distribution: Click the + on the right to add additional assets.Would you like to designate any contingent beneficiaries?* Yes No We recommend designating contingent beneficiaries. These beneficiaries would be the recipients of your estate in the event that all initial beneficiaries have passed before you. Please describe below your contigent beneficiaries:Name:Relationship:Addess:Phone:Percent of Distribution: Click the + on the right to add additional assets. Δ
