Florida Estate Planning Questionnaire

CONTACT INFORMATION

Name

First Last

Spouse Name

First Last

Other or former names

Other or former names of Spouse

Your Birthdate

Your Birthplace

Spouse birthdate

Spouse Birthplace

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email

If you have moved to Florida from another state, name the state and years of residence there, including the date you moved to Florida.

Do you have other residences in Florida?

Yes
No

Are you a U.S. citizen?*

Yes
No

If you are a U.S. citizen other than by birth, please state date of citizenship.

Is your spouse a U.S. citizen?*

Yes
No

If your spouse is a U.S. citizen other than by birth, please state date of citizenship.

Driver's license number

Your Occupation

Your Employer

Spouse's Occupation

Spouse's Employer

FAMILY DATA

Do you have children (including stepchildren or foster children)?

Yes
No

If yes, please provide the following information for each: Name, Living?, Birthdate, Married?, and City/State of Residence

For each child, state the name of the child's other parent if not your present spouse.

Do you have children in college?

Yes
No

Do you anticipate sending a child or children to college in the future?

Yes
No

Do your children own any valuable assets?

Yes
No

If so, name the child and the approximate value of the asset:

Do you have dependents other than minor children?*

Yes
No

If so, please provide name, age, and residence for each.

If you have stepchildren, do you want them treated the same as your natural born or legally adopted children in your Will?*

Yes
No
Does not apply to me

If yes, state the following for each: Name, Age, Birthdate, and Parent name(s)

Do you have any grandchildren?*

Yes
No
Does not apply to me

If yes, state the following for each: Name, Age, Birthdate, and Parent name(s)

Are any of your children or other beneficiaries mentally or physically disabled or have special needs?*

Yes
No
Does not apply to me

If yes, please note any special provisions.

If your children are under age eighteen (18), state the following for the person you wish to act as their legal guardian (custodian) in the event of your death or in case of joint death or you and your spouse (if married). You should obtain the consent of that person(s) before executing your Will. Please list Name(s), Address, and Relationship.

If at the time of your death the person(s) named above is/are unwilling to serve as guardian (custodian), please list an alternate including Name(s), Address, and Relationship

Do you want the appointed guardian also to be the trustee (conservator) of any assets inherited by the minor children?*

Yes
No

At what age would you like your children to take control from the trustee of any inherited assets? (Must be at least 18 years old.)

If no, please list the person or entity you wish to act as their financial custodian. You should obtain consent of that person or entity before executing your Will. Include Name(s), Address, and Relationship

Please list an alternate in case this person is unwilling or unable to serve including Name(s), Address, and Relationship

Please list the names of your parents, brothers, and sisters, and state whether they are living, and if so, list their city and state of residence.

List, as well, the same information for your spouse's parents and siblings.

Do you presently have a Will?

Yes
No

If so, what is the date on the Will?

Was it signed in Florida?

Yes
No

If not, where?

Does your spouse presently have a Will?

Yes
No

If so, what is the date on the Will?

Was it signed in Florida?

Yes
No

If not, where?

Are you a beneficiary, trustee (singly or jointly), or creator of a trust?

Yes
No

If so, what is the date of the trust?

Is your spouse a beneficiary, trustee (singly or jointly), or creator of a trust?

Yes
No

If so, what is the date of the trust?

Have you signed a prenuptial or postnuptial agreement?

Yes
No

If so, what is the date of the agreement and name of the spouse involved?

Please provide the following information regarding your former marriages including name(s) of former spouse, state whether they are living, and the date of death or divorce agreement.

Please provide the following information regarding your spouse's former marriages including name(s) of former spouse, state whether they are living, and the date of death or divorce agreement.

ASSETS AND LIABILITIES

Indicate how you want your assets to pass when you die. Please check the ONE option you prefer:

Option A: I want my assets to pass to my spouse and children as follows:

To my spouse, if surviving.
If my spouse predeceases me, my assets will be divided in equal shares to my children.
Is any of my children predecease me, that child’s share shall be distributed to his or her children in equal shares.

In the event my spouse and all of my children and descendants fail to survive me, I want my assets to be distributed as follows:

Option B: I am unmarried with children and want my assets to pass on as follows:

In equal shares to my children.
If one or more of my children predeceases me, that child’s share in my estate is distributed to his or her children in equal shares.

In the event all of my children and descendants fail to survive me, I want my assets to be distributed as follows:

Option C: None of the above. I want my assets to pass as follows:

Do you wish to disinherit any children or grandchildren? If so list their names here. Note: In certain states, it is not possible to completely disinherit a spouse or minor child.

Execution of a Will is the best way to determine how your property will be distributed. However, is cannot address important issues regarding health care decisions. Our firm may prepare a Health Care Power of Attorney, Living Will and Durable Power of Attorney for you. Who would you like to serve as your representative responsible for making your health care decisions and managing your non-health care matters should you become incapacitated?

Please list an alternate in case this person is unwilling or unable to serve including Name(s), Address, and Relationship

Please indicate your wishes by checking one box below:

I want this person to be able to act on my behalf immediately.
I want this person to be able to act on my behalf only upon certification by a doctor that I am no longer able to make decisions and act for myself.

If married and your spouse is still alive, do you want your spouse to serve as your personal representative/executor?

Yes
No

Please list an alternate below. If not married or you wish to appoint someone other than your spouse, please indicate below including Name(s), Address, and Phone Number.

Please list an alternate in case this person is unwilling or unable to serve including Name(s), Address, and Phone Number.

Do you wish to waive the fiduciary bond requirement?

Yes
No

Many people make special provisions for family heirlooms, jewelry, or other items of special value to be distributed to friends or relatives. If you have such property and would like to leave it to a specific person, please complete the following including the Item, Special Identifying Features, and the Recipient's Full Name..

Liquid assets: cash (dividends, etc.); savings accounts; checking accounts; money market accounts; certificates of deposit; mutual funds. Include Item Identification/Account Number, Location (Name/Address of Bank), and Value

Other personal property (everything except liquid assets): private corporation stocks and bonds (publicly listed); unlisted stocks and bonds; government bills, notes, and bonds; commodities; automobiles; other vehicles (airplanes, boats, motorcycles, recreational vehicles); precious metals; safe deposit contents; household goods, furniture, and appliances; china, crystal, and silver; jewelry (watches, wedding and engagement rings); furs and clothing; art works, photographs, letters, medals, collectibles, family heirlooms, artifacts, and antiques; tools and machinery; computers and electronic equipment; sports equipment (camping, hiking, cycling, skiing, fishing, etc.); hobbies; camera, video, and recording equipment; books; musical instruments; valuable livestock/animals; pets; money owed to you (personal loans, etc.); vested interest in profit sharing plan, stock options, etc.; limited partnerships; trust interest; vested interest in retirement plans, IRAs, death benefits, annuities; life insurance; miscellaneous personal property not already listed. Include the Item, Location, and Value.

Separately identify valuable items. Categorize less valuable items (for example, "all of my clothing," "all of my household possessions," etc.). Household possessions can include furniture, appliances, tools, etc. State where listed assets are located (for example, provide the address or, if applicable, state "at my residence." List shares of stock by number of shares, name of company, and type of stock (for example, 100 shares of General Electric common). When listing the value of the asset, first list the total value, then subtract any debt owing on the asset and list the net value of the asset. If the asset is a life insurance policy, IRA, or retirement plan, identify any primary or contingent beneficiaries listed on the policy, account, or plan. Take into account accrued income tax liability when valuing a retirement plan.

Business personal property: patents, copyrights, trademarks, and royalties; business ownerships such as partnerships, sole proprietorships, corporations, etc. (list by name and type of business); miscellaneous receivables (such as mortgages, deeds of trust, or promissory notes held by you; rents due from income-producing property owned by you; payments due for professional or personal services or property sold by you that are not fully paid by the purchaser). Include the Item, Location, and Value.

Real estate: agricultural land; boat/marina slip; cemetery plots; condominiums; cooperatives; timeshares; duplexes; houses; mobile homes; rental properties; undeveloped land; vacation homes. Include the Property Address (including county) and Value.

Describe real property by listing its address or location, including the street address or apartment number or acreage in a specified county. The legal description does not have to be provided. If the real property includes personal items such as farm tools or animals, include them in the description, specifically listing expensive items such as cattle or a tractor. If the items are relatively inexpensive, such as tools in a shed on otherwise vacant land, state "along with all personal property located on the property." Subtract any mortgage or other debt owing on the asset.

TOTAL NET VALUE OF ALL ASSETS

LIABILITIES

To reach the net value of assets listed above, you should already have listed and subtracted the debt on the asset. Therefore, you should include below only those liabilities not taken into account above. Do not include regular monthly bills such as those for utilities, telephone, and credit cards, but do take into account whether you have guaranteed any obligations of someone else (even if you don't expect to have to pay).

Personal property debts (personal loans with banks, major credit card debt, etc.) and other personal debts. Include Item Description, Amount Due, and Due Date

Taxes (include only past and currently due taxes - do not include future or estimated estate taxes). Include Item Description, Amount Due, and Due Date

Other liabilities (such as legal judgments, guarantees, accrued child support, etc.). Include Item Description, Amount Due, and Due Date

TOTAL LIABILITIES

NET WORTH

INCOME AND HEALTH ISSUES

Annual income and source of income (wages, rents, dividends, etc.)

Spouse's annual income and source of income (wages, rents, dividends, etc.)

Describe your health (good, fair, poor) and any illnesses that you suffer from:

Provide the same information for your spouse:

State the name and contact information for your physician:

Provide the same information for your spouse:

Do you have health insurance?

Yes
No

If yes, please provide the name of the company and contact information:

Provide the same information for your spouse:

Do you have disability insurance?

Yes
No

If yes, please provide the name of the company and the value of the insurance:

Provide the same information for your spouse:

CONSULTANTS

Name and contact information for your attorney:

Provide the same information for your spouse, if different:

Name and contact information for your accountant:

Provide the same information for your spouse, if different:

Name and contact information for your insurance agent:

Provide the same information for your spouse, if different:

Name and contact information for your investment advisor (broker, banker, etc.):

Provide the same information for your spouse, if different:

Family Security

A. Liquid Funds Available to Family

1. Savings (S1 - S6)

2. Marketable Securities (G1 - G6)

3. Life Insurance (P9)

4. Pre Tax Assets (S9)

5. Deferred Tax Assets (S7 - S8)

6. Other Liquid Assets

Total:

B. Non-Liquid Assets

1. Primary Residence (G8)

2. Real Estate (G8)

3. Collectibles (G7)

4. Tax Shelters (G9)

Total:

C. Liquid Cash Needs of Family

Immediate Cash Needs

1. Final Expenses

2. Debts Paid Off

3. Federal Estate Taxes

4. State Inheritance Taxes

5. Income Taxes

Total:

Discretionary Cash Needs

1. Mortgage Liquidation

2. Educational Fund

3. Safety Fund

Total:

D. Net Liquid Funds Available to Family

Total:

E. Other Income

1. Net From Section D at 4.00 %

2. Government Survivor Beneﬁts

3. Other Income

4. Income From Non-Liquid Assets

Results

Total Current Income:

Desired Income for Family:

Desired Income Shortfall:

Additional Funds Required to Provide Desired Income:

Life Insurance for Consideration

Guideline Maximum:

Presently Owned:

Additional Amount Available:

Additional Amount to Own:

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