Estate Planning Questionnaire
Download the Mark Allen Law Office Estate Planning Questionnaire by clicking the button below. Once you have carefully filled out the questionnaire bring it in to our office for a consultation so that we can advise you on your best course of action.
Date: ______________
PERSONAL INFORMATION
Name:
Address:
Phone Numbers:
Billing Address if different:
U.S. Citizen? YES_____ NO_____
Current marital status: Single _____ Married _____ Widowed _____ Divorced_____
SPOUSE
Name:
Phone Numbers:
U.S. Citizen? YES_____ NO_____
CHILDREN
Name (Indicate if any are minors, adopted, are stepchildren or are children from a prior marriage. Indicate any you are specifically omitting from inheriting from your estate.)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
OTHER PERSONS WHO WILL BENEFIT UNDER YOUR ESTATE PLAN
Name and what they will inherit (list percentages, specific amounts, or specific items)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
ESTATE ADMINISTRATORS
Personal Representative(s) or Trustee(s) – (the person in charge of your Finances):
Name:
Address:
Phone: __________________________________________________________
First Successor Trustee(s):
Name:
Address:
Phone: __________________________________________________________
Second Successor Trustee(s):
Name:
Address:
Phone: __________________________________________________________
Guardian(s) – (the person(s) responsible for raising your minor children who are 17 years old or younger):
Name:
Address:
First Successor Guardian(s):
Name:
Address:
Second Successor Guardian(s):
Name:
Address:
Healthcare Agent (s) – (the person(s) responsible for ensuring your healthcare wishes are fulfilled if you are unable to do so):
Name:
Address:
Phone: __________________________________________________________
First Successor Agent(s):
Name:
Address:
Phone: __________________________________________________________
Second Successor Agent(s):
Name:
Address:
Phone: __________________________________________________________
FINANCIAL INFORMATION
- Real Estate owned by you (list addresses):
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- Cash and Savings (indicate if there is a payable on death beneficiary or someone other than your spouse named on the account):
| Name of Bank | Account Number | Checking or Savings? |
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
HEALTHCARE INFORMATION
Any information provided here is used to draft a Healthcare Power of Attorney with Living Will Provisions. Keep in mind that this is a medical, legal document. As such the provisions are medically related, and you should seek advice from a medical provider in reviewing this document and addressing any questions you may have before it is finalized. I am happy to offer my opinion on the legal aspects of the document, but cannot provide you with medical advice.
Once finalized, you should ensure that the document is kept on file at the healthcare facility you normally use and with all of your regular doctors.
Do you want to be an organ or body donor? _______________________________
Any specific requests? (e.g. lifesaving transplant only?)________________________________________________________________________________________
Do you have any religious or other beliefs that may require additional instruction in light of conventional medical treatments? ____________________________________________________________________________________________________________________________________________________________________________
If you are ever in a vegetative state, kept functioning through artificial means, and 2 doctors agree you will not recover, what would you like your healthcare provider to do?___________________________________________________________________________________________________________________________________________________________________________________________________
Do you wish to receive end-of-life care including:
Pain medications? ____________________
Even if they expedite death? _______________
Never give the following medications: _____________________________________
Artificial Hydration? _______________________
Artificial Nutrition? _______________________
Do you have any other requests in end of life or other healthcare? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Do you wish to be cremated? ______________