(SINGLE
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. 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. Residence
Home
Address ____________________________________________
________________________________________________________
Home
Telephone No._______________________________________
Fax
No. (do we need to call you before faxing?)__________________
Other
Residences__________________________________________
________________________________________________________
Resident
Since _____________________________________
3. Billing Address (if different)
________________________________________________________
________________________________________________________
4. 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
5. Please circle any of the following
states in which you have lived or acquired property:
Arizona Idaho Nevada Texas
California Louisiana New Mexico Washington
Canada None of the above
6. Names of Children (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_________________________________________
7. 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 _________________________
______________________________________________________________________
8. 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 ________________________________________
_______________________________________________________________________
9. Do you have any legal obligations to a
former spouse or children? ___ Yes
___ No
If
Yes, please provide copy of relevant document(s).
10. Do you have a present Will? ___ Yes
___ No
If
Yes, please attach a copy.
11. Do you have any present Trusts? ___ Yes
___ No
If
Yes, please attach a copy.
12. Have you ever received a substantial
amount by inheritance?
__
Yes __ No If Yes, when? ____________
Approximate amount $__________
Do
you anticipate receiving an inheritance?
___ Yes ___ No
If
Yes, give approximate amount $______________
13. Do you hold a power of appointment under
another person’s Will or Trust?
___Yes
___ No If yes, please attach a copy.
14. Have you given away more than $10,000 in
money or property to any person in any single year after 1976? ___ Yes
___ No
Have
you ever been required to file a gift tax return?
___
Yes ___ No If Yes, what years?
_____________________________
Please
attach copies of any gift tax returns.
15. Do 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
16. Are you a party to a Shareholder or
Partnership Agreement (including any Buy-Sell Agreements)?
___
Yes ___ No
If
Yes, please attach a copy.
17. Do you have a safe deposit box? ___ Yes
___ No
If
Yes, where located? ______________________________________________
Name(s)
box is listed under __________________________________________
18. Do you own any property in a foreign
country? ___ Yes ___ No
If
Yes, give country and approximate value $____________________________
19. Please list any specific items or
amounts that you wish to give to any individuals or organizations:
Name
and Relationship
of
Beneficiary Description
of Gift
___________________________ __________________________________________________
___________________________ __________________________________________________
___________________________ __________________________________________________
___________________________ __________________________________________________
20. All other tangible personal property
(automobiles, clothing, furniture, pictures, etc.) to be distributed to (check
one):
___
Children equally
___
Other (specify) __________________________________________________________
__________________________________________________________________________
21. All remaining money and other property
(stocks, bonds, mutual funds, etc.) to be distributed to:
___
Children equally
___
Other (specify) __________________________________________________________
__________________________________________________________________________
22. 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_______________________________________
23. 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?
______________________________________________
________________________________________________________________________________________.
24. Please indicate below your choice as Executor
(Personal Representative) of your estate and Successor Trustee of your Living
Trust (if applicable). You will be the
initial Trustee of your 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 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 estate and Successor Trustee of your Living
Trust?
Name: ___________________ _____________________
Relationship: ___________________ _____________________
Please
name alternates to serve if your first choice cannot:
First
Alternate
Name: ___________________ _____________________
Relationship: ___________________ _____________________
Second
Alternate
Name: ___________________ _____________________
Relationship: ___________________ _____________________
25. Your choice to act as Guardian of your
minor children (if applicable):
First
choice
Name(s)
_________________________________ Relationship: _______________________
Address
____________________________________________________________________
Second
choice
Name(s)
_________________________________ Relationship: _______________________
Address
____________________________________________________________________
26. Are you presently involved in any
litigation, or is there litigation or potential claims against you that are
known? ____ Yes ____ No
27. Are you engaged in any high-risk
ventures, professions, or circumstances that would make creditor planning
important? _____ 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.
___________________________________________
Client
LIST
OF ASSETS
(Attach
additional sheets if necessary)
Approximate
Net Values
┌─────────┬─────────┬─────────┐
1.
Real Estate(please give approximate
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value and approximate mortgage balance)│
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Home - Value $______________
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Approximate mortgage balance
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$_____________
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Other Real Estate (give location or
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briefly describe:)________________
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2.
Stocks, Bonds, Mutual Funds
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A. Publicly traded stock--Name
of │
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corporation.
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______________________________
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B. Closely held stock--Name
of │
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corporation, number of shares
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and shareholders.
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______________________________
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______________________________
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Approximate
Net Values
┌─────────┬─────────┬─────────┐
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C. Bonds and mutual
funds--Issuer, │
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face value, interest rate, and
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maturity date; name of fund,
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fund group, and number of units.
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3.
Bank accounts, certificates of
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deposit, money market funds, etc.
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Please give name of bank or institu-
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tion, type of account and approximate
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balance or value.
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4. IRA’s and Pension Plan
Assets │
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5.
Mortgages, notes, or debts (owed to
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you by someone else).
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Please list debtor's name, date
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acquired, and approximate balance
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remaining.
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___________________________________
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Approximate
Net Values
┌─────────┬─────────┬─────────┐
6.
Other Business Interests (noncorporate)│
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___________________________________
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7.
Partnership or other investments not
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listed above.
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8.
Miscellaneous Property
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Motor vehicles (including boats, etc.; │
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List total value)
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Jewelry │
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Art, other valuable items (describe)
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9.
List any mortgages or other substan-
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tial debts owed by you that are not
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shown above.
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____________________________________
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└─────────┴─────────┴─────────┘
10.
Life Insurance
Loans
Person
Policy Against
Company Death
Value Cash Value Insured Owner Beneficiary Policy
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
11. List
any contingent liabilities, litigation, etc.
_____________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________