Consultation questionnaire

Information about you
Your Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
County*
Phone*
Email
Your date of birth*
MM slash DD slash YYYY
Do you have any special needs, disabilities or serious medical conditions?*
- Yes
- No
Please describe
Do you currently have any of the following documents (check all that apply)?
- Will
- Trust
- Medical / Health Care Power of Attorney
- General Durable Power of Attorney ("Financial Power of Attorney")
- Advance Medical Directive / Health Care Directive (aka "Living Will")
- Guardianship for minors
- I'm not sure

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Information about your spouse
Name
First Middle Last
Phone
Email
Spouse date of birth*
MM slash DD slash YYYY
Does your spouse have any special needs, disabilities or serious medical conditions?*
- Yes
- No
Please describe
Does your spouse currently have any of the following documents (check all that apply)?
- Will
- Trust
- Medical / Health Care Power of Attorney
- General Durable Power of Attorney ("Financial Power of Attorney")
- Advance Medical Directive / Health Care Directive (aka "Living Will")
- Guardianship for minors
- I'm not sure

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Information about your children
Please identify for each child:*
Full Name Age Date of birth Any special needs or disabilities?

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Financial Information
Estimate your family's net worth (assets minus debts):
- Under $250,000
- $250,000 to $750,000
- $750,000 to $1.5M
- $1.5M or above
Which of the following statements best describes how you and your spouse manage your assets:
- We combine most of our assets
- We combine some assets and hold some assets separately
- We hold most of our assets separately
Do you have a pre-nuptial agreement?
- Yes
- No
Do you own your primary residence?
- Yes
- No
(Select yes even if you have a mortgage)
Who is identified as the owner on the deed?
Do you own any other real property?
- Yes
- No
For each property, please state:
Type of property (rental home, land, etc.) Address Who owns the property? Is there a mortgage?
Do you have a 401k, IRA or other pre-tax retirement plan?
- Yes
- No
Does your spouse have a 401k, IRA or other pre-tax retirement plan?
- Yes
- No
Do you have stocks, bonds or other equities held in a non-retirement account?
- Yes
- No
Does your spouse have stocks, bonds or other equities held in a non-retirement account?
- Yes
- No
Do you have life insurance?
- Yes
- No
Does your spouse have life insurance?
- Yes
- No
Are you currently receiving social security benefits?
- Yes
- No
Do you or your spouse currently receive social security benefits?
- Yes
- No
Do you own any part of a business (such as a sole proprietorship, LLC or partnership)?
- Yes
- No
Describe the type of business
Do you or your spouse own any part of a business (such as a sole proprietorship, LLC or partnership)?
- Yes
- No
Describe the type of business
Do you own any valuables such as jewelry, artwork, antiques, guns, collectible cars, other collectibles or any other asset that you wish to include in your estate plan?
- Yes
- No
Please describe
Do you wish to plan for charitable giving as part of your estate plan?
- Yes
- No
Please describe

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Estate Planning Consultation Questionnaire

Step 1 of 6

Information about you

Family Information

Information about your spouse

Information about your children

Financial Information

Other Information

Type of property (rental home, land, etc.)	Address	Who owns the property?	Is there a mortgage?

Full Name	Age	Date of birth	Any special needs or disabilities?