ESTATE PLANNING INTAKE QUESTIONNAIRE

Transcription

1 Cathy R. Cook Ethan J. Arenstein Attorneys at Law Scott M. Brooks, Paralegal 114 East Eighth Street, Cincinnati, Ohio Elizabeth J. Byrd, Legal Assistant Phone: Fax: ESTATE PLANNING INTAKE QUESTIONNAIRE Today s Date: YOUR PERSONAL INFORMATION Your Complete Legal Your Fax: Is call needed before fax sent?: Drivers License Number: Date of Marriage: Date of Divorce: Present Health: Safe Deposit Box(es) Locations: Name on Box: Name on Box: Name on Box: Other Residences: DOMICILE(S) Prior Residences: 1

2 BUSINESS/EMPLOYMENT Name of Business/Employment: Business Phone: Type of Business: Form of Ownership (sole proprietor, partner, limited partner, corporation, other): ESTIMATED INCOME FOR CURRENT YEAR Base Salary Bonus and Other Compensation Taxable Dividends and Interest Tax-Exempt Income Capital Gains or Losses Other Income (Specify) Total Client Spouse MILITARY SERVICE Your branch of service: Your dates of service: Your rank: Your service number: Date of discharge: Your service-connected disabilities (%): Your pension and retirement information is located: CASH, BANK ACCOUNTS, CERTIFICATES OF DEPOSIT INFORMATION Name on Account: Account Type: Bank/Institution: Number: Maturity Dates: Name on Account: Account Type: Bank/Institution: Number: Maturity Dates: 2

3 Name on Account: Account Type: Bank/Institution: Number: Maturity Dates: Name on Account: Account Type: Bank/Institution: Number: Maturity Dates: REAL PROPERTY INFORMATION (Include Residential, Business, Recreational, Rental, Timeshare, Foreign Real Estate, Other) Type: Name(s) on Title: Title Held By: Assessed Value: Insurance: Type: Name(s) on Title: Title Held By: Assessed Value: Insurance: Type: Name(s) on Title: Title Held By: Assessed Value: Insurance: SECURITIES, STOCKS, BONDS, GOVERNMENT BONDS INFORMATION STOCKS Title: Date of Death Value: Company Number of Shares: Type of Stock (Common or Preferred): Certificate Numbers: Title: Date of Death Value: Company Number of Shares: Type of Stock (Common or Preferred): Certificate Numbers: U.S. SAVINGS BONDS Title: Serial Number: Date of Issue: Accrued Interest: Date of Death Value: Title: Serial Number: Date of Issue: Accrued Interest: Date of Death Value: 3

4 BONDS Title: Serial Number: Issuer: Date of Issue: Bond Type: Interest Note: Maturity Date: Face Amount: Value at Maturity: Date of Death Value: Face Amount: Title: Serial Number: Issuer: Date of Issue: Bond Type: Interest Note: Maturity Date: Face Amount: Value at Maturity: Date of Death Value: Face Amount: Insurer: Policy Number: Insurer: Policy Number: INSURANCE AND ANNUITIES ON LIFE INFORMATION Beneficiary: Amount: Beneficiary: Amount: MOTOR VEHICLES TANGIBLE PERSONAL PROPERTY Make, Model, Year Who uses item Titleholder VIN Number Loan Company Loan Balance Monthly Payments Are Payments Current? Insurance Coverage 4

5 OTHER VEHICLES (BOATS, TRAILERS, CAMPERS, MOTORBIKES, ETC.) Make, Model, Year Who uses item Titleholder VIN Number Loan Company Loan Balance Monthly Payments Are Payments Current? Insurance Coverage ASSETS Assets Husband Wife Joint Personal Effects Home (Principal) Other Real Estate Bank Accounts & Certificates of Deposit Marketable Securities Non-Marketable Securities Business Interests Life Insurance IRAs or Similar Accounts Pension or Profit-Sharing Benefits Tax Shelter Investments Other Assets Total 5

6 LIABILITIES Liabilities Husband Wife Joint Current Debts Bank Loans Mortgages Payable Income Taxes Life Insurance Loans Other Debts Total Estimated Combined Present Net Worth: Estimated Value of Estate (including insurance and employment benefits): MISCELLANEOUS ASSET INFORMATION Are you currently a beneficiary of an estate or trust? (Includes trusts where you have an expectancy after a prior interest): If yes, please state: Name of Estate/Trust Relationship Trustee Value of Your Interest Do you have any expected inheritances from your parents or other relatives?: state: Person Who May Leave You Something If yes, please Relationship Age Value of Your Interest 6

7 Are you serving as executor or trustee of any estate or trust?: If yes, please state: Estate or Trust Other Trustees Value Attorney Handling Describe any other contingent asset you have been entitled to receive (i.e. negligence recovery): CHILDREN AND STEP-CHILDREN 7

8 GRANDCHILDREN 8

9 9

10 PARENTS, SPOUSE S PARENTS, AND OTHER DEPENDENTS Ante-nuptial or Postnuptial Agreements: FAMILY CONCERNS Previous Marriages: Children of Previous Marriages: Divorce or Legal Separation: Settlement Information (child support, etc.): Special Dependency Cases (handicapped child, relative): Mental Disability: Emotional Problems: Other Health Problems: INFORMATION FOR LAST WILL AND TESTAMENT 10

11 EXECUTOR/EXECUTRIX 11

12 If above named agent is not available: FIRST ALTERNATE AGENT SECOND ALTERNATE AGENT GUARDIAN FOR MINOR CHILDREN If above named agent is not available: FIRST ALTERNATE AGENT 12

13 SECOND ALTERNATE AGENT AGENT OF DURABLE POWER OF ATTORNEY If above named agent is not available: FIRST ALTERNATE AGENT SECOND ALTERNATE AGENT 13

14 AGENT OF DURABLE HEALTH CARE POWER OF ATTORNEY If above named agent is not available: FIRST ALTERNATE AGENT SECOND ALTERNATE AGENT 14

15 INFORMATION FOR LIVING WILL FIRST CONTACT SECOND CONTACT DONOR REGISTRY Do you wish to be listed on the Donor Registry?: ACCOUNTANT FAMILY ADVISORS ATTORNEY TAX PREPARER BANKER 15

16 PHYSICIAN INSURANCE PLANNER/AGENT TRUST OFFICER STOCK BROKER APPRAISER OTHER OTHER OTHER 16

17 SPECIFIC BEQUESTS (contained in Last Will & Testament) Party Item Received Approximate Value WISHES REGARDING DIVISION OF PROPERTY AND ASSETS 17