Estate Planning Questionnaire Please complete this questionnaire prior to our first estate planning meeting so that our meeting can be as efficient and productive as possible. Thank you! General BackgroundNote, if you are married or in a relationship and we are meeting with both of you, both of you may certainly complete your own form; or, in the alternative, one of you may complete the entire form and the other person needs to only submit his/her GENERAL BACKGROUND information. This form is only to help Attorney Buchheit get to know a bit about you and your goals, and also to help you start thinking about some of the questions. Your answers to the questions are only a starting point, and all questions, plus several others, will be discussed in detail during your meeting.Date - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY Full name * RequiredFirst, middle, and lastAddress * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number(s) * RequiredDesignate *home; * mobileEmailList all emails where you would like us to contact you regarding your estate plan.Current Age * RequiredEmployer * RequiredPlease indicate how long employed here (or retired, if applicable)Marital Status * RequiredIndicate if Single; Divorced; Engaged; or Married (indicate if common law is applicable)Spouse's legal name (if applicable)Date of Marriage (if applicable)Do you have a Prenuptial / Premarital Agreement?If the answer to this questions is "Yes," please bring a copy of the prenuptial agreement with you to our meeting. Yes No Referral SourcePlease state how you found us.Estate Planning QuestionsNote, the following questions are only to get you brainstorming. We will discuss all of these questions, and many more, at our meeting. Do not in any way feel bound by your answers.Estate Planning GoalsPlease indicate your primary estate planning goals Control distribution of assets Minimize family conflict Asset protection Tax planning Other Disabilities / Special NeedsPlease indicate if any of your loved ones or potential beneficiaries (people to whom you may leave assets) have special needs or disabilities. Special Needs Disability Other Biological or adopted childrenFor each child, please create rows by hitting the (+) button. Please list each child's (1) name; (2) address; (3) phone number; (4) age; and (5) marital status.Child 1Child 2Child 3 Additional biological or adopted childrenFor each child, please create rows by hitting the (+) button. Please list each child's (1) name; (2) address; (3) phone number; (4) age; and (5) marital status.Child 4Child 5Child 6 GrandchildrenList your biological / adopted grandchildren by (1) legal name; (2) town and state residing in; and (3) age. Please also designate each grandchild's parent by name.Step-Children or Step-GrandchildrenIf you have any step-children or step-grandchildren you may want to include in your estate plans, please list them by name, address, and phone number.Family DynamicsPlease describe any family dynamics which may be of importance to your estate plan (e.g. estranged family members; siblings fighting; a loved one with drug, alcohol, or health issues; a loved one who has difficulty managing money; etc.)Asset Distribution * RequiredDescribe generally how you would like your assets to be distributed (e.g. everything to spouse, then my children as long they are age 25)ConditionsDo you want to place conditions on your beneficiaries receiving their inheritance? (e.g. if a spouse remarries; age requirements; educational milestones; no illegal drugs; etc.)AgentsThe next section is intended to get you thinking about who may be best equipped to carry out the terms of your Last Will and Testament or Trust. Likewise, if you have a minor child or act as a guardian of an adult with special needs, consider who you would want to step in your shoes to fulfill this role in your absence.Executor * RequiredAn ideal executor is reliable, trustworthy, diligent, and be able to keep the peace with people while still standing firm. An executor may charge for his/her/its duties. Begin brainstorming (family, friends, bank / trust departments, etc.) Try to think of 2-3 options if possible.TrusteeClients often underestimate the work of a Trustee. An ideal Trustee will have the same characteristics as an ideal Executor, but also be somewhat financially savvy and know when and how to ask for professional assistance if needed. A Trustee may charge for his/her/its services. Begin brainstorming of potential Trustees (banker, corporate trust departments, family members, friends, etc.). Try to think of 2-3 options if possible.GuardianIf both you and your spouse (if applicable) were gone, who would you want to care for your minor children (or children with special needs)? The guardian reports annually to the Court and makes decisions regarding health, education, residence, religion, etc. This is a tough decision. Begin brainstorming only:ConservatorIf you and your spouse (if applicable) are gone, who would you want to manage the financial affairs of your minor child (or person with special needs, if applicable)? The Conservator gives and accounting to the Court annually.Powers of AttorneyIt is very important to have a power of attorney. These take effect during your life, but if you become disabled or of unsound mind. If you become of unsound mind and don't have a power of attorney, a guardianship and conservatorship is usually required to be filed with the Court.Financial Power of Attorney * RequiredBegin brainstorming in order of preference who you may want to handle your finances (pay your bills, sell assets, etc.) if you are living but become of unsound mind. State the person's legal name, address, and phone number.Medical Power of Attorney * RequiredIf you are living but are diagnosed with Alzheimer's, for example, or are otherwise unable to make medical decisions for yourself, who might be some individuals you would trust to make health, educational, and residential decisions for you? Please state the person's legal name, address, and phone number.Living WillA living will is a paragraph which can be added to your medical power of attorney if you wish. The living will indicates if a doctor determines you are terminally ill and permanently unconscious and on life support, you desire to have life support removed, although you may still receive medications to keep you comfortable. Please indicate if you think you want a living will:YESNOUNSUREOrgan DonationIf, at your death, any of your organs could be used, do you desire to be an organ donor? YESNOUNSUREDo you have any of the following?: Long term care insurance Burial plot Prepaid funeral arrangements None of the above AdvisorsAccountant / CPAName and address of accountant (if any)Financial AdvisorName and address of financial advisor(s), if anyASSETSIf you have a financial statement or list of assets, please bring to our meeting. We will primarily focus not on amounts, but rather, who is on the title (the owner(s)) and who are the beneficiaries of the asset, if any (e.g. life insurance owned by you, with spouse as primary beneficiary and children as alternate beneficiaries). Do you have any of the following? checking account(s) savings account(s) certificates of deposit (CD's) stocks or bonds annuities retirement plan (pension, IRA, Roth IRA, 401K, etc.) life insurance Land / Real EstateList all real estate you own or of which you have a legal interest.BusinessesList all businesses you own or have a legal interest in. If the business is incorporated, please provide the legal business name and state of incorporation. Do you or your spouse anticipate inheriting from someone in the future?MOST LIKELYNOEstate TaxThe current estate tax exemption is approximately $11 Million per person (or $22 Million per married couple). Do you believe your entire estate may or could in the future be close to these amounts? If so, we will discuss potential tax planning in greater detail if tax avoidance is important to you.YESNOUNSUREAre you concerned about family conflict?YESNOUNSUREAre you concerned about divorce among your children or beneficiaries?YESNOUNSUREOtherIf there are certain questions or facts you want to ensure we address, please feel free to describe here.PhoneThis field is for validation purposes and should be left unchanged.