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

  1. Real Estate owned by you (list addresses):

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

  1. 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? ______________

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