CONFIDENTIAL ESTATE
PLANNING INFORMATION FORM
(MARRIED
INDIVIDUALS)
This
questionnaire was developed for use by ALAN S. GASSMAN, P.A. in designing
comprehensive estate plans for clients.
The information which you supply on this form will be retained in our
files and no information will be released to any person without your prior
permission.
DATE: _____________________
1. Husband
Full Name
________________________________________________ Date of Birth ________
Social Security No.
_________________________________________ Place
of Birth _______
Other Names Known By
_____________________________________ Citizenship
__________
_________________________________________________________
Occupation
(former if retired) _________________________________
Employer
_________________________________________________
Office
Telephone No. ________________________________________
Fax
No. (do we need to call you before faxing?)___________________
Any
serious health problems? __ Yes __
No
2. Wife
Full Name
_________________________________________________ Date of Birth ________
Social Security No.
__________________________________________ Place
of Birth _______
Other Names Known By ______________________________________ Citizenship
__________
__________________________________________________________
Occupation
(former if retired) __________________________________
Employer
__________________________________________________
Office
Telephone No. ________________________________________
Fax
No. (do we need to call you before faxing?)___________________
Any
serious health problems? __ Yes __
No
3. Residence
Home
Address ______________________________________________
__________________________________________________________
Home
Telephone No._________________________________________
Fax
No. (do we need to call you before faxing?)____________________
Other
Residences____________________________________________
__________________________________________________________
Husband
State Resident Since________________________________
Wife
State Resident Since___________________________________
4. Billing Address (if different)
________________________________________________________
________________________________________________________
5. Advisors
Accountant________________________________________________ Phone Number_____________
Trust
Officer_______________________________________________ Phone Number_____________
Insurance
Agent___________________________________________ Phone Number_____________
Investment
Advisor________________________________________ Phone Number_____________
Pension
Plan Advisor_______________________________________ Phone Number______________
May
we speak to your advisors directly? ___ Yes ___ No
6. Marriage
A. Date of Marriage
____________________________________
B. Where Living When
Married___________________________
C. Prior Marriages (Husband) ___ Yes ___ No
(Wife) ___ Yes
___ No
If prior marriage ended in divorce, please provide copy of
decree and settlement.
D. Is there a Prenuptial Agreement or
other marital contract in effect?
___ Yes ___ No If yes, please attach a copy.
E. Please circle any of the following
states in which you have lived or acquired property while married:
Arizona Idaho Nevada Texas
California Louisiana New Mexico Washington
Canada None of the above
7. Names of Children of Present Marriage
(if adopted, indicate (A) after name; if deceased, please indicate (D) after
name):
A. Name________________________________________________ Date of
Birth_________
Social Security Number__________________________________
Name of Child’s Spouse (if any)___________________________
Address______________________________________________
Grandchildren_________________________________________
B. Name________________________________________________ Date of
Birth_________
Social Security Number__________________________________
Name of Child’s Spouse (if any)___________________________
Address______________________________________________
Grandchildren_________________________________________
C. Name________________________________________________ Date of Birth_________
Social Security Number__________________________________
Name of Child’s Spouse (if any)___________________________
Address______________________________________________
Grandchildren_________________________________________
D. Name________________________________________________ Date of
Birth_________
Social Security Number__________________________________
Name of Child’s Spouse (if any)___________________________
Address______________________________________________
Grandchildren_________________________________________
E. Name________________________________________________ Date of
Birth_________
Social Security Number__________________________________
Name of Child’s Spouse (if any)___________________________
Address______________________________________________
Grandchildren_________________________________________
8. List any children of prior marriages
(indicate husband’s or wife’s by indicating (H) or (W) after name; if adopted,
indicate (A) after name; if deceased, please indicate (D) after name):
A. Name________________________________________________ Date of
Birth_________
Social Security Number__________________________________
Name of Child’s Spouse (if any)___________________________
Address______________________________________________
Grandchildren_________________________________________
B. Name________________________________________________ Date of
Birth_________
Social Security Number__________________________________
Name of Child’s Spouse (if any)___________________________
Address______________________________________________
Grandchildren_________________________________________
C. Name________________________________________________ Date of
Birth_________
Social Security Number__________________________________
Name of Child’s Spouse (if any)___________________________
Address______________________________________________
Grandchildren_________________________________________
D. Name________________________________________________ Date of
Birth_________
Social Security Number__________________________________
Name of Child’s Spouse (if any)___________________________
Address______________________________________________
Grandchildren_________________________________________
E. Name________________________________________________ Date of
Birth_________
Social Security Number__________________________________
Name of Child’s Spouse (if any)___________________________
Address______________________________________________
Grandchildren_________________________________________
9. Are there any family members who
require special schooling, special medical attention, or other special
attention? ____ Yes ____ No
If
Yes, please give name(s) and describe nature of needs _________________________
______________________________________________________________________
10. Do you have any other relatives now or
likely in the future to be dependent upon you for support?
___
Yes ___ No
If
Yes, give name(s) and relationships ________________________________________
_______________________________________________________________________
11. Do either of you have any legal
obligations to a former spouse or children? ___ Yes ___ No
If
Yes, please provide copy of relevant document(s).
12. Do either of you have a present
Will? ___ Yes ___ No
If
Yes, please attach a copy.
13. Do either of you have any present
Trusts? ___ Yes ___ No
If
Yes, please attach a copy.
14. Have either of you ever received a
substantial amount by inheritance?
__
Yes __ No If Yes, when? ____________
Approximate amount $__________
Do
either of you anticipate receiving an inheritance? ___ Yes ___ No
If
Yes, give approximate amount $______________
15. Do either of you hold a power of
appointment under another person’s Will or Trust?
___Yes
___ No If yes, please attach a copy.
16. Have either of you given away more than
$10,000 in money or property to any person in any single year after 1976? ___ Yes
___ No
Have
either of you ever been required to file a gift tax return?
___
Yes ___ No If Yes, what years?
_____________________________
Please
attach copies of any gift tax returns for either spouse.
17. Do either of you work for a business
which has some type of plan under which your estate or the person you specify
will receive benefits on your death?
___
Yes ___ No ___ Not Sure
18. Are either of you a party to a
Shareholder or Partnership Agreement (including any Buy-Sell Agreements)?___
Yes ___ No
If
Yes, please attach a copy.
19. Do either of you have a safe deposit
box? ___ Yes ___ No
If
Yes, where located? ______________________________________________
Name(s)
box is listed under __________________________________________
20. Do either of you own any property in a
foreign country? ___ Yes ___ No
If
Yes, give country and approximate value $____________________________
21. Please list any specific items or
amounts that you wish to give to any individuals or organizations:
Donor
(Husband or Name and
Relationship
Wife) of
Beneficiary Description
of Gift
__________________ _____________________ __________________________
__________________ _____________________ __________________________
__________________ _____________________ __________________________ __________________ _____________________ __________________________
22. All other tangible personal property
(automobiles, clothing, furniture, pictures, etc.) to be distributed to (check
one):
___
Spouse; if spouse predeceases, to children equally
___
Children equally
___
Other (specify) __________________________________________________________
__________________________________________________________________________
23. All remaining money and other property
(stocks, bonds, mutual funds, etc.) to be distributed to:
___
Spouse; if spouse predeceases, to children equally
___
Children equally
___
Other (specify) __________________________________________________________
__________________________________________________________________________
24. If you have named a beneficiary in
Questions 20-22 above for whom full personal information has not already been
provided (for example, a parent, aunt/uncle, niece/nephew, or friend), please
provide that information here:
A. Name____________________________________________ Date of
Birth_________
Address__________________________________________
Relationship_______________________________________
B. Name____________________________________________ Date of
Birth_________
Address__________________________________________
Relationship_______________________________________
C. Name____________________________________________ Date of
Birth_________
Address__________________________________________
Relationship_______________________________________
25. Age(s) at which beneficiaries are to
become in control of property held in trust for them or are to receive property
outright--see attached Memorandum entitled Trust Systems for Children and
Subsequent Generations.
(A) Traditional approach - distribute
selected percentages at selected ages to the extent not otherwise spent.
(B) Protective approach - child becomes
Co-Trustee at what age, selects Co-Trustee at what further age, and becomes
sole Trustee at what eventual age?
______________________________________________
________________________________________________________________________________________.
26. With reference to surviving spouse, do
you think he or she may be benefited by serving as Co-Trustee with a protective
individual or trust company of his or her choice (changeable by him or her) in
order to be able to have protection from future spouses and creditors?
______________________________________________________.
27. Please indicate below your choices as Executor
(Personal Representative) of your estates and Successor Trustee of your Living
Trusts (if applicable). Each of you
will be the initial Trustee of your own Living Trust. The Successor Trustee will act if you cannot due to resignation,
incapacity or death. You may select an individual or a financial institution
with trust powers under your state law to act as Executor and Successor
Trustee. You may also select more than
one person or institution to act as Co-Executors or Co-Trustees at the same
time, and you may provide that they may act with or without the joinder and
consent of the other. Most clients select the same persons to act as both Executor
and Successor Trustee, but that’s strictly a matter of personal choice.
Who
will serve as Executor of your estates and Successor Trustees of your Living
Trusts?
Each
spouse for the other? ___ Yes ___ No
If
No, whom? Husband Wife
Name: ___________________ _____________________
Relationship: ___________________ _____________________
Please
name alternates to serve if your first choice cannot:
Husband Wife
First
Alternate
Name: ___________________ _____________________
Relationship: ___________________ _____________________
Second
Alternate
Name: ___________________ _____________________
Relationship: ___________________ _____________________
28. Your choice to act as Guardian of your
minor children (if applicable):
First
choice
Name(s)
_________________________________ Relationship: _______________________
Address
____________________________________________________________________
Second
choice
Name(s)
_________________________________ Relationship: _______________________
Address
____________________________________________________________________
29. Are you presently involved in any
litigation, or is there litigation or potential claims against you that are
known? ____ Yes ____ No
30. Are you engaged in any high-risk
ventures, professions, or circumstances that would make creditor planning
important? _____ Yes _____ No
Under
the Florida Bar Rules, any information given to us by one spouse or relating to
planning is accessible to the other spouse.
Each spouse has the right to independent legal counsel with respect to
planning. The transfer of assets with
respect to estate planning could affect marital rights. Do you have any questions about this?
___
Yes ___ No
We
will do your planning based upon the information described in this form. If you wish for us to verify any of this information,
please let us know. We will be pleased
to review any Deeds, Mortgages, account statements, or other confirmatory
documentation, if requested. The
specific ownership and designation of assets, liabilities and beneficiary
designations must be coordinated properly for estate planning documents to
function as intended.
The
undersigned has reviewed this form and the following asset summary information
and believe it to be accurate.
____________________________________________
Husband
___________________________________________
Wife
LIST
OF ASSETS
(Attach
additional sheets if necessary)
Approximate
Net Values
┌─────────┬─────────┬─────────┐
│ Husband │
Wife │
Joint │
1.
Real Estate(please give approximate
│
│
│
│
value and approximate mortgage balance)│
│
│
│
Home - Value $______________
│
│
│
│
Approximate mortgage balance
│
│
│
│
$_____________
│
│
│
│
Other Real Estate (give location or
│
│
│
│
briefly describe:)________________
│
│ │
│
__________________________________
│
│
│
│
│ │ │
│ __________________________________ │
│
│
│
│
│
│
│
__________________________________
│
│
│
│
│
│
│
│
__________________________________
│
│
│
│
│
│
│
│
2.
Stocks, Bonds, Mutual Funds
│
│
│
│
│
│
│ │
A. Publicly traded stock--Name
of │
│
│
│
corporation.
│
│
│
│
│
│
│
│
______________________________
│
│
│
│
│
│
│
│
______________________________
│
│
│
│
│ │
│
│
______________________________
│
│
│
│
│
│
│
│
B. Closely held stock--Name
of │
│
│
│
corporation, number of shares
│
│
│
│
and shareholders.
│
│
│
│
│
│
│
│
______________________________
│
│
│
│
│
│
│
│
______________________________
│
│
│
│
Approximate
Net Values
┌─────────┬─────────┬─────────┐
│ Husband │ Wife
│ Joint
│
│
│
│
│
C. Bonds and mutual
funds--Issuer, │
│ │
│
face value, interest rate, and
│
│
│
│
maturity date; name of fund,
│
│
│
│
fund group, and number of units.
│
│
│
│
│
│
│
│
_______________________________
│
│
│
│
│
│
│
│
_______________________________
│
│
│
│
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│
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│
│
│
3.
Bank accounts, certificates of
│
│
│ │
deposit, money market funds, etc.
│
│
│
│
│
│
│
│
Please give name of bank or institu-
│
│
│
│
tion, type of account and approximate
│
│
│
│
balance or value.
│
│
│
│
│
│
│
│
__________________________________
│
│
│
│
│
│
│
│
__________________________________
│
│
│
│
│
│
│
│
__________________________________
│
│
│
│
│
│
│
│
4. IRA’s and Pension Plan
Assets │
│
│
│
__________________________________ │
│
│
│
│
│
│
│
__________________________________ │
│
│
│
│
│
│
│
__________________________________ │
│
│
│
│
│
│
│
5.
Mortgages, notes, or debts (owed to
│
│
│
│
you by someone else).
│
│
│
│
│
│
│
│
Please list debtor's name, date
│
│
│
│
acquired, and approximate balance
│
│
│
│
remaining.
│
│
│
│
___________________________________
│
│
│
│
│
│
│
│
___________________________________
│
│
│
│
Approximate
Net Values
┌─────────┬─────────┬─────────┐
│ Husband │
Wife │
Joint │
6. Other Business Interests
(noncorporate)│
│
│
│
│
│
│
│
___________________________________
│
│
│
│
│
│
│
│
___________________________________
│
│
│
│
│
│
│
│
7.
Partnership or other investments not
│
│
│
│
listed above.
│
│
│
│
│
│
│
│
8.
Miscellaneous Property
│
│
│
│
│
│
│
│
Motor vehicles (including boats, etc.; │
│
│
│
List total value)
│
│
│
│
│
│
│
│
Jewelry
│
│
│
│
Art, other valuable items (describe)
│
│
│
│
│
│
│
│
_____________________________________
│
│
│
│
│
│
│
│
9.
List any mortgages or other substan-
│
│
│
│
tial debts owed by you that are not
│
│
│
│
shown above.
│
│
│
│
____________________________________
│
│
│
│
____________________________________
│
│
│
│
____________________________________
│
│
│
│
└─────────┴─────────┴─────────┘
10.
Life Insurance
Loans
Person
Policy Against
Company Death
Value Cash Value Insured Owner Beneficiary Policy
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
11. List
any contingent liabilities, litigation, etc.
_____________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________