Initial Questionnaire

The purpose of this Initial Questionnaire is to record information that will be used to prepare your Estate Plan, including, as necessary, a Will, Trust, Durable Power of Attorney, and Healthcare Power of Attorney. All information is essential. Portions of it will be helpful in the administration of the Estate or Trust and, in some cases, is required for the preparation of tax returns. Your time spent in accurately completing this Questionnaire will certainly save considerable time, effort and confusion later.

YOUR INFORMATION
Client #1 - Full Legal Name*
First Middle Last Suffix
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Birthdate*
MM
DD
YYYY
SS#
Cell Phone
Home Phone
US Citizen?*
- Yes
- No
Email*
Marital Status*
- Single
- Married
- Divorced
- Widowed
If Divorced, Name of Previous Spouse*
Pets*
- Yes
- No

SPOUSE'S INFORMATION (if applicable)
Client #2 - Full Legal Name
First Middle Last Suffix
Address (if different)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Birthdate
MM
DD
YYYY
SS#
Cell Phone
Home Phone
US Citizen?
- Yes
- No
Email
Marital Status
- Single
- Married
- Divorced
- Widowed
If Divorced, Name of Previous Spouse
Pets
- Yes
- No

ADDITIONAL PERSONS' INFORMATION
(If going to be included in your Estate Plan and NOT a child or spouse)
Others #1 - Full Legal Name
First Middle Last Suffix
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Relationship to you
(i.e. wife's brother, husband's friend, etc.)
Others #2 - Full Legal Name
First Middle Last Suffix
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Relationship to you
(i.e. wife's brother, husband's friend, etc.)
Others #3 - Full Legal Name
First Middle Last Suffix
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Relationship to you
(i.e. wife's brother, husband's friend, etc.)

ADVISORS (if applicable)
FINANCIAL ADVISOR / WEALTH MANAGER
Financial Advisor - Name
First Last
Company
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Email
Satisfied
- Yes
- No
CPA / ACCOUNTANT
CPA - Name
First Last
Company
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Email
Satisfied
- Yes
- No

ASSETS & INCOME
Below please provide your best estimate at the information requested, exact values are not necessary for the initial consultation. If both husband and wife have separate accounts or separate income, please separate them out on the line provided. An example would be "Husband-1500 Wife-1250".
Income - Wages
Income - Social Security
Income - Pension
Income - Other
Primary Residence Approximate Value
Additional Real Estate Approximate Value
Checking / Savings
Stocks / Bonds
IRA / 401K
Life Insurance
Annuities
Vehicles
Other Assets
Outstanding Mortgage
Other Outstanding Debt
Phone
This field is for validation purposes and should be left unchanged.

Initial Questionnaire

YOUR INFORMATION

SPOUSE'S INFORMATION (if applicable)

CHILDREN'S INFORMATION (if applicable)

CHILD #1

CHILD #2

CHILD #3

CHILD #4

ADDITIONAL PERSONS' INFORMATION

ADVISORS (if applicable)

FINANCIAL ADVISOR / WEALTH MANAGER

CPA / ACCOUNTANT

REAL ESTATE / OTHER PROPERTY / VACATION OR INVESTMENT

PROPERTY #1

PROPERTY #2

PROPERTY #3

PROPERTY #4

ASSETS & INCOME

1-800-378-2837

(1-800-378-2837)

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