CLIENT INFORMATION

DOCUMENTS TO RETURN WITH THIS QUESTIONNAIRE

Please check all documents that are relevant to either you and/or your spouse, if applicable, and provide us with a copy of the applicable documents, if possible:

LAST WILL AND TESTAMENT

A Last Will and Testament is document by which you identify those individuals (or charities) that are to receive your property and possessions on your death. A Personal Representative is the individual(s) you name to manage your affairs and probate your Will after you pass. Please note that under Florida law, if the personal representative is not related to you, or the spouse of someone related to you, he or she must be a Florida resident. You may also select “joint” personal representatives or a “corporate” personal representative (e.g., bank or trust company).

WHO ARE YOUR BENEFICIARIES?

TRUSTS

If you are considering establishing a trust during your life or after your death for a spouse, child, grandchild, parent or another person or charity (especially to avoid payment of large sums of money to a beneficiary at one time, or prior to a beneficiary attaining a certain age, or for a specific purpose), whom do you want to nominate as the trustee? You may also select “co-trustees” or a “corporate” trustee (e.g., bank or trust company).

Durable power of attorney is a document authorizing another person to control your assets on your behalf and for your benefit. This document takes effect immediately upon execution (i.e., this is not simply just effective if and when you become incapacitated). It is important that you choose an individual that you feel will always act in your best interest and manage your assets in the same manner you would.

DESIGNATION OF HEALTHCARE SURROGATE

Designation of Healthcare Surrogate is a document authorizing another person to carry out your wishes in the event you are unable to communicate your decisions concerning extending, withholding or withdrawing life-prolonging procedures under certain legally-permissible circumstances.

Living Will is a document which reflects your decision regarding the withholding or withdrawal of life prolonging procedures in the event you should have a terminal condition. It also specifies instructions for your surrogate with regard to end-of-life decisions. If you desire to have a Living Will, this can be prepared as a separate document, or together with your Designation of Healthcare Surrogate. Just let us know how you would prefer. There is no right or wrong answer.

SUMMARY OF ASSETS AND LIABILITIES

Note: The following is a financial summary for estate and tax planning purposes. Further detailed information and copies of documents concerning particular assets and liabilities may be requested. In lieu of completing this summary, you may substitute a current financial statement.

  • ESTATE PLANNING QUESTIONNAIRE
  • DOCUMENTS TO RETURN WITH THIS QUESTIONNAIRE
  • LAST WILL AND TESTAMENT
  • WHO ARE YOUR BENEFICIARIES?
  • TRUSTS
  • DURABLE POWER OF ATTORNEY
  • DESIGNATION OF HEALTHCARE SURROGATE
  • LIVING WILL
  • SUMMARY OF ASSETS AND LIABILITIES

Client Information

Legal Name (first, middle, last)

List all prior legal names

List all other names used

Date of birth

Place of birth (city, state, country

Social Security Number (no dashes)

U.S. Citizen

Florida resident

Permanent Address (street address, city, state, zip, country)

Do you claim Florida homestead exemption

Telephone number (Home)

Telephone number (Work)

Telephone number (Cell phone)

Occupation

Employer

Marital status

Marital history: Have you ever been divorced or widowed?

Family Information

Spouse

Date of marriage

City

State

Country

Legal name of spouse (first, middle, last)

Maiden name

Date of birth spouse

Social Security number (no dashes)

U.S. Citizen

Florida Resident

Telephone number - home

Telephone number - work

Telephone number - Cell phone

Occupation

Employer

Marital history: Have you ever been divorced or widowed?

Children
If you have any children, please state the legal name, birth date and current address of each of your children and state whether a child has any children (i.e., your grandchildren). Do not include a step child or foster child who lives with you.

Legal Name (first, middle, last)

Current Address (street address, city, state, zip)

Date of birth

Children number

Telephone number

Is this child of a current or prior marriage:

Is this child disabled or does he/she have special needs:

Has any child predeceased you?

Did they have children?

If you or your children have adopted or do adopt a child, should the adopted child be treated the same as a natural child?

Do any children have creditor problems, problems managing finances or marital issues that could affect their receiving property outright? If so, please describe.

Documentation

Do you currently have any existing wills or trusts, including “Living Wills” or “Living Trusts?”

Have you made any gifts in excess of the federal exclusion amount ($15,000) per year to any person? If yes, please include gift tax returns.

Are you a party to a pre- or post- nuptial agreement, divorce decree or marital agreement? If yes, please provide a copy with all subsequent modifications.

Are you the beneficiary or do you have a Power of Appointment in any will or trust created by someone else?

Do you have an interest in any business? If so please attach any and all documentation regarding what happens to your interest upon your death. (e.g., partnership agreement, Limited Liability Company Agreement, shareholder agreement, stock option plan, buy-sell agreement, etc.)

Do you have an existing Power of Attorney/Advance Directive for management of property or health care?

Personal Representative

Legal name: (first, middle initial, last)

Current address (street address, city, state, zip, country)

Relationship to you:

Alternate Personal Representative

Legal name: (first, middle initial, last)

Current address (street address, city, state, zip, country)

Relationship to you:

Some probate judges will allow the personal representative to serve without having to post a bond if the decedent’s will waives the bond requirement. Other judges refuse to allow a waiver because of concerns about protecting estate creditors and beneficiaries from misfeasance or nonfeasance. NOTE: A fiduciary bond is a type of surety bond required by the court to ensure proper performance of duties.

Do you want your personal representative or alternate to be required post a bond (which is paid by your estate) to be able to serve?

GUARDIANS

If you have any children who are minors, a guardian should be named in your will to care for their person and to manage their property until they attain 18 years of age in the event of the death of both parents. You may nominate “joint” guardians. You may also nominate separate guardians for a child, that is, a “guardian of the person” and a “guardian of the property” especially if a proposed guardian may not be suitable for handling a child's property and finances. A guardian of the property could include a “corporate” guardian or corporate co-guardian. Please note that under Florida law, if the person you nominate as guardian is not related to the child, he or she must be a Florida resident to be appointed.

Legal name: (first, middle initial, last)

Current address (street address, city, state, zip, country)

Relationship to you:

Alternate Guardian

Legal name: (first, middle initial, last)

Current address (street address, city, state, zip, country)

Relationship to you:

A. SPECIFIC BEQUESTS

List any specific items (e.g., automobiles, jewelry, personal effects, etc.) or specific amounts of money that you wish to leave to one or more beneficiaries. If you have a large number of items of “tangible personal property” that you want to give to several persons, you may want to consider having a “separate writing” prepared.

Item or Amount

Name of Beneficiary

Address of Beneficiary

Relationship

If a beneficiary of a specific bequest does not survive you, state who is to receive his or her share (e.g., the children of that beneficiary or one or more other persons).

2. RESIDUE (the rest)

Please indicate, by checking the appropriate option, how you want your assets to pass when you die. Please feel free to make modifications by annotating the options to best suit your needs and wishes. For information on leaving funds/assets to minors, see the section titled “MINORS”

If a residuary beneficiary does not survive you, state who is to receive his or her share (e.g., the children of that beneficiary or one or more other persons).

TRUSTS

Describe some of the general provisions you think are important.

Trustee

Primary Trustee

Legal name: (first, middle initial, last)

Current address (street address, city, state, zip, country)

Relationship to you:

Alternate Trustee

Legal name: (first, middle initial, last)

Current address (street address, city, state, zip, country)

Relationship to you:

Do you want your trustee or alternate to be required to post a bond (which is paid from the trust assets) to be able to serve?

Additional information

Use this space to provide any additional information concerning your testamentary intentions.

At what age(s) do you want the monies to be distributed to your children/beneficiaries? List percentages (For example: 25% at age 21, 25% at age 25, 50% at age 30, and 100% at age 35):

List any other distributions you would like made to your trust beneficiaries, for example: “A one time distribution of $25,000.00 to each of my children for the purchase of a real property.”

List any instructions regarding limitations on distributions (such as must finish college, etc.), or special situations (such as starting a business, getting married, etc.).

Primary Agent Information

Legal name: (first, middle initial, last)

Current address (street address, city, state, zip, country)

Relationship to you:

Alternate Agent

Legal name: (first, middle initial, last)

Current address (street address, city, state, zip, country)

Relationship to you:

Second Alternate Agent

Legal name: (first, middle initial, last)

Current address (street address, city, state, zip, country)

Relationship to you:

Health care surrogate

Legal name: (first, middle initial, last)

Current address (street address, city, state, zip, country)

Relationship to you:

Telephone number - Home:

Telephone number - Work:

Alternate health care surrogate

Legal name: (first, middle initial, last)

Current address (street address, city, state, zip, country)

Relationship to you:

Telephone number - Home:

Telephone number - Work:

If you are designating more than one person to act as your health care surrogate, choose one of the following:

If you have named two surrogates and wish to designate a third, please let us know. These documents are tailored to your wishes. Do not hesitate to specify exactly what you want.

If you would like to name additional surrogates, please provide their information below.

Living Will

Here are some general statements about choices you have as to health care you want at the end of your life. Put a check next to whichever choices best fit your wishes. Any combination can be used but if you choose “Direction to Prolong My Life (to the greatest extent possible)”, no other choices should be checked.

Do You Have Specific Limitations on Medical Treatments I Want: (NOTE: mark one or more choices below.) If I have a terminal condition, or am in an irreversible coma or a persistent vegetative state that my doctors reasonably believe to be irreversible or incurable, I do want the medical treatment necessary to provide care that would keep me comfortable, but I do not want the following:

Direction to Prolong My Life:

How Long?

Religious Assistance. My designated representative(s), in the order indicated, shall have the right to contact the religious leader of the religious organization of which I am a member at the time this Living Will is implemented, if applicable, to seek guidance and assistance for me during the dying process, so that all may be done in a manner consistent with my religious beliefs.

Euthanasia:

Organ Donation:

Disposition of Remains:

Tangible Personal Property

By default, your tangible personal property (such as furniture, vehicles, jewelry or artwork) will be distributed according to your directions in your Will. Only complete the Tangible Personal Property chart if you have tangible personal property that you would like to go to a particular person or the property is of substantial value (famous artwork, diamonds, etc.). Please complete this section if you are concerned that those who inherit under your will not be able to reach an accord on the distribution of certain pieces of property, to minimize potential conflicts.

Description

Location

Approximate Value

Safe Deposit Boxes

Financial Institution

Name(s) on the Account

Contents

Bank Accounts

Financial Institution

Name(s) on the Account

Payable on Death? (Y/N)

If POD, Named Beneficiary

Approximate Balance

Stocks, Bonds, Treasury Notes, Other Investments (Not Real Property)

Name on Certificate or Book Entry

Payable on Death? (Y/N)

No. of Shares

Approximate Value

Real Estate

Please provide a copy of the deed for each property.

Description (Residence, Investment, and etc.)

Address (Street, City, State and Zip Code)

Name on Deed

Approximate Value

Business Interests

Business Owners: Please provie tax id number, exact business name, and how you wish for ownership to pass under your Will. If succession plan is available, please include.

Name of Owner

Description (Partnership, LLC, Corporation, etc)

Approximate Market Value

Life Insurance, IRA's, Pernsions, 401(k)s, Annuities

Type

Financial Institution

Account/Policy Holder No.

Current Beneficiary

Approximate Face Value

Mortage, Notes, and Other Receivables (Payable/Owed to YOU)

Name of Debtor

Description of Debt

Current Balance Owed to YOU

Motor Vehicles

Name of Owner

Description (Make, Model, Year, VIN)

Approximate Market Value

Other Assets (Trusts, Investment Interests, Anticipated Inheritances ro Gifts, Lawsuits)

Description

Name of Owner

Approximate Value

Mortgage(s) on homestead

Client (only)

Jointly with Spouse

Jointly with Others

Total

Mortgage(s) on other real property

Client (only)

Jointly with Spouse

Jointly with Others

Total

Personal or unsecured debt you owe to others

Client (only)

Jointly with Spouse

Jointly with Others

Total

Other significant debts, liabilities and judgements

Client (only)

Jointly with Spouse

Jointly with Others

Total

Total Liabilities

Client (only)

Jointly with Spouse

Jointly with Others

Total

Miscellaneous

Please provide the name, address and telephone number of your:
It is important to us to have the information of those you work closely with to maintain your financial health. In addition, when your relatives are managing your estate or trust, they will need guidance and they may not know who to call. This information will help us better serve your relatives after your passing. You are more than welcome to pass along our contact information to these professionals as well!

Accountant:

Investment broker:

Insurance agent:

Financial planner:

Banker:

Confirmation of information and instructions: I confirm the information provided by me in this questionnaire is complete and accurate, and that the instructions I am providing reflect my wishes.

Date:

Signed:

Whom may I thank for the referral?