Estate Planning Form

1
Estate Plan Client Questionnaire

Congratulations, this form will provide you with a copy of your answers. It is a tool to help identify your needs & goals. This has only 15 questions.

If you don't have all of the answers that's okay. You can revisit the form to complete it later.
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The purpose of this is to gather information and to make sure we have names spelled correctly. We are not making any decisions at this time. If you make a mistake or don't have all of the information please go ahead and complete the form. We are available if you have any issues.
3
Are you married?* This field is required.Click yes if needed for a married couple.
Yes
No
4
Your Name* This field is required.
First Name
Middle Name
Last Name
Jr., Sr. III etc
5
Husband Name* This field is required.
First Name
Middle Name
Last Name
Jr., Sr. III etc
6
Your Email* This field is required.
example@example.com
7
Husband Email* This field is required.
example@example.com
8
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Phone Number
Area Code
Phone Number
10
Name of Wife* This field is required.
First Name
Middle Name
Last Name
Jr., Sr. III etc
11
Wife's Contact InformationOptional. Please provide all available information.
Spouse Email
Spouse Phone
12
Couple: Questions about childrenClick all that apply
We have no children
We have children together (check if spouse adopted other's child)
Husband has children from a previous relationship
Wife has children from a previous relationship
One or more of the children is deceased
13
Do you have children?
Yes, all are living.
Yes, but one or more are deceased.
No Children.
14
Children Info: Please include information about living childrenPlease include at least the name and date of birth for each. If a child is deceased we'll ask about that later.
Name
Date of Birth
Address
Phone
Email
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
1 of 6
15
Our Children Info: Please include information about living childrenPlease include at least the name and date of birth for each. If a child is deceased we'll ask about that later.
Name
Date of Birth
Address
Phone
Email
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
1 of 6
16
Husband Children Info: Please include information about living childrenPlease include at least the name and date of birth for each. If a child is deceased we'll ask about that later.
Name
Date of Birth
Address
Phone
Email
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
1 of 6
17
Wife Children Info: Please include information about living childrenPlease include at least the name and date of birth for each. If a child is deceased we'll ask about that later.
Name
Date of Birth
Address
Phone
Email
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
Name
Date of Birth
Address
Phone
Email
1 of 6
18
Did any deceased child have decedents?If a child died but left children of his or his own please complete.
YesNo
19
Deceased child informationIf a deceased child left children please provide information here.
Name
Child 1
Child 2
Child 3
Child 4
Deceased Child 1
Deceased Child 2
Deceased Child 3
Deceased Child 1
Deceased Child 2
Deceased Child 3
Name
Child 1
Child 2
Child 3
Child 4
Name
Child 1
Child 2
Child 3
Child 4
Name
Child 1
Child 2
Child 3
Child 4
Name
Child 1
Child 2
Child 3
Child 4
1 of 4
20
Others to include in your estate plan. Optional.Please list other persons, charities or entities to include in your estate plan. These may be beneficiaries or persons that may serve as a executor, power of attorney, etc. Remember we are just gathering information at this point.
Name
Connection to you
Address
Phone
Email
One
Two
Three
Four
Five
One
Two
Three
Four
Five
Name
Connection to you
Address
Phone
Email
Name
Connection to you
Address
Phone
Email
Name
Connection to you
Address
Phone
Email
Name
Connection to you
Address
Phone
Email
Name
Connection to you
Address
Phone
Email
1 of 5
21
Special situations:* This field is required.Are any of the beneficiaries disabled, mentally challenged or would need assistance managing money?
Yes
No
22
Concerns: OptionalBriefly identify the individual and explain your concerns.
Huge
Large
Normal
Small
Ok
Ok
23
Current plan: If you have a current plan, please check any that apply. Click Next if you do not have a plan.
Will
Power of Attorney-Financial
Power of Attorney-Healthcare
Advanced Healthcare Directives
HIPAA Releases
Trust
24
What are your objectives?Click all that apply.
Keep in control
Get things set up to keep things simple for me and my family.
Avoid Probate
Avoid Guardianship
Medicaid Planning
Tax Savings
Asset Protection for Me or Children
Current Estate Plan Out of Date
25
Do you have any questions or concerns?
26
Check the box the click "SEND" so that your information can be delivered.* This field is required.
Should be Empty: