Estate Questionnaire Step 1 of 6 16% Husband Personal InformationFull Legal Name First Last Preferred Name First Last Home Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code County Email Alternate Email PhoneMobile PhoneWork PhoneDOB MM slash DD slash YYYY U.S. Citizen? Yes No Asset DistributionPlease describe generally how you want your assets distributed (e.g. to all my children, equally):Specific BequestsDo you have any specific bequests (e.g., I leave my ’77 Corvette to my son, Mike of Raleigh, North Carolina)? Yes No Specific Bequest DescriptionIf yes, please describe:Distribution of AssetsIf none of your children survived you and your spouse, how would you want to distribute your assets (e.g., to a named charity or to specific persons)? Charitable Organization BequestsDo you wish to make bequests to any charitable organization? Yes No Charitable Organization Bequest DescriptionIf yes, please list name(s) and amount / description:Wife Personal InformationFull Legal Name First Last Preferred Name First Last Home Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code County Email Alternate Email PhoneMobile PhoneWork PhoneDOB MM slash DD slash YYYY U.S. Citizen? Yes No Asset DistributionPlease describe generally how you want your assets distributed (e.g. to all my children, equally):Specific BequestsDo you have any specific bequests (e.g., I leave my ’77 Corvette to my son, Mike of Raleigh, North Carolina)? Yes No Specific Bequest DescriptionIf yes, please describeDistribution of AssetsIf none of your children survived you and your spouse, how would you want to distribute your assets (e.g., to a named charity or to specific persons)? Charitable Organization BequestsDo you wish to make bequests to any charitable organization? Yes No Charitable Organization Bequest DescriptionIf yes, please list name(s) and amount / description. Children and BeneficiariesFull Legal Name First Last Preferred Name First Last RelationshipRelationship (e.g. child of H or W or both, adopted, step-child, grandchild, etc.): DOB MM slash DD slash YYYY U.S. Citizen? Yes No Spouse's Name First Last Children's Names:Inheritance InstrucionsSpecific Instructions Regarding Inheritance:Additional Comments(e.g. special needs): Additional children or beneficiaries? Yes No List multiple children or beneficiaries below: Designated PersonsIn this section, please identify the persons designated to act on your behalf in the listed capacities.Executor: An executor is the person named in your will who is given the legal responsibility to administer your estate and take care of your remaining financial obligations.Husband First Choice Relationship to Husband Husband 1st Alt. Executor Relationship to Husband Husband 2nd Alt. Executor Relationship to Husband Wife First Choice Relationship to Wife Wife 1st Alt. Executor Relationship to Wife Wife 2nd Alt. Executor Relationship to Wife Trustee for Minor Children Trust: Your will may include provisions putting assets to be disbursed to minor children into trust until they reach a determined age. The named trustee will administer the trust assets in accordance with the will.Husband First Choice Relationship to Husband Husband 1st Alt. Executor Relationship to Husband Husband 2nd Alt. Executor Relationship to Husband At what age would you like assets distributed in full to your children?(e.g. 18, 25, etc.)Wife First Choice Relationship to Wife Wife 1st Alt. Executor Relationship to Wife Wife 2nd Alt. Executor Relationship to Wife At what age would you like assets distributed in full to your children?(e.g. 18, 25, etc.)Guardian: The will should identify one or more persons to serve as guardian of any minor children if you and your spouse pass away. Doing so allows you to make this decision, rather than leaving it in the hands of the courts. You can name a single guardian or co-guardians (e.g. sister and brother-in-law).Husband First Choice Relationship to Husband Husband 1st Alt. Executor Relationship to Husband Husband 2nd Alt. Executor Relationship to Husband Wife First Choice Relationship to Wife Wife 1st Alt. Executor Relationship to Wife Wife 2nd Alt. Executor Relationship to Wife Guardian: This person will make financial decisions for you in the event you are unable to do so for yourself.Husband First Choice Relationship to Husband Husband 1st Alt. Executor Relationship to Husband Husband 2nd Alt. Executor Relationship to Husband Type of power of attorney? Durable Springing Wife First Choice Relationship to Wife Wife 1st Alt. Executor Relationship to Wife Wife 2nd Alt. Executor Relationship to Wife Type of power of attorney? Durable Springing Health Care Power of Attorney: This person will make medical decisions for you in the event you are unable to do so for yourself.Husband First Choice Relationship to Husband Husband 1st Alt. Executor Relationship to Husband Husband 2nd Alt. Executor Relationship to Husband Type of power of attorney? Durable Springing Wife First Choice Relationship to Wife Wife 1st Alt. Executor Relationship to Wife Wife 2nd Alt. Executor Relationship to Wife Type of power of attorney? Durable Springing Trustee: If your estate plan will incorporate trust planning (e.g. revocable or irrevocable trust), the trustee will administer the trust.Husband First Choice Relationship to Husband Husband 1st Alt. Executor Relationship to Husband Husband 2nd Alt. Executor Relationship to Husband Wife First Choice Relationship to Wife Wife 1st Alt. Executor Relationship to Wife Wife 2nd Alt. Executor Relationship to Wife Healthcare Decision-Maker for Children: If you and your spouse are unavailable for a period of time, who do you want to make these decisions for your children? It mayHusband First Choice Relationship to Husband Husband 1st Alt. Executor Relationship to Husband Wife First Choice Relationship to Wife Wife 1st Alt. Executor Relationship to Wife Additional QuestionsHave you or your spouse previously engaged in estate planning?(e.g. will, trust, powers of attorney, etc.) Yes No If yes, please provide a brief description and date:Date MM slash DD slash YYYY When did you establish residency in North Carolina?If you have ever been a resident outside North Carolina during your present marriage, provide the county, state, and approximate dates of each residency:Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Date Range Have you or your spouse ever been divorced or widowed? Yes No Name First Last Date MM slash DD slash YYYY Do you, your spouse or any dependents or relatives have any health concerns or special educational, medical, financial, or other personal needs? Yes No If yes, please describe:Do you have any additional dependents for whom you are or be will be providing support? Yes No If yes, please describe:Are you or your spouse receiving social security or disability benefits? Yes No Have you or your spouse ever filed federal gift tax returns? Yes No Are you or your spouse making annual gifts to anyone? Yes No Have you and/or your spouse ever signed a pre- or post-nuptial agreement? Yes No If Yes, please provide a copy.Max. file size: 50 MB.Do you or your spouse serve as custodian or trustee of assets of others? Yes No If yes, please describe:Have you or your spouse received or do you expect to receive any substantial gifts or inheritances? Yes No If yes, please describe:Do you own unique assets, like antiques or works of art, which may require special consideration or valuation? Yes No If yes, please describe:Do you have any special requests regarding your funeral, burial, cremation or the disposition of your remains? Yes No If yes, please describe:Would you like to leave instructions regarding your wishes for end-of-life medical care, in case you become unable to communicate their decisions?(i.e., a living will or healthcare directive) Yes No Do you think you would wish to receive medical treatment which will only postpone the moment of your death from an incurable and terminal condition or prolong an irreversible coma? Yes No PLEASE NOTE: We will talk in greater detail about questions 14 and 15, including options, questions and concerns, but please provide an initial answer now as best you can.Do you and/or your spouse wish to discuss additional trust planning, tax planning, charitable giving, special needs planning or other special concerns? Yes No If yes, please describe: AdvisorsPlease provide the name, company info, phone and email information for the followiong, if applicable.Attorney:Name First Last Company PhoneEmail Accountant:Name First Last Company PhoneEmail Financial PlannerName First Last Company PhoneEmail Life Insurance AgentName First Last Company PhoneEmail Personal BankingName First Last Company PhoneEmail Business BankingName First Last Company PhoneEmail OtherName First Last Company PhoneEmail Asset SummaryThe purpose of this section is to determine an approximate value of the estate, which will help identify needs and options for the intended estate plan. For each asset category, please provide an estimated value or approximate balance for assets held by you and your spouse, as well the total debt against such assets. This will include assets held individually by either spouse and assets held jointly. Depending on the results of this summary, additional and more detailed information may be required to properly determine appropriate estate planning needs and structure.Real EstateEstimated Value/Approximate BalanceLoan/Debt BalanceCash AccountsEstimated Value/Approximate BalanceLoan/Debt BalanceInvestment Accounts/Mutual FundsEstimated Value/Approximate BalanceLoan/Debt BalanceStocks and BondsEstimated Value/Approximate BalanceLoan/Debt BalanceAutomobiles (e.g. cars and boats)Estimated Value/Approximate BalanceLoan/Debt BalanceGeneral Household ItemsEstimated Value/Approximate BalanceLoan/Debt BalanceSpecial Household Items (e.g. art)Estimated Value/Approximate BalanceLoan/Debt BalanceIRA's, 401(k) plans, annuities, etc.Estimated Value/Approximate BalanceLoan/Debt BalanceLife InsuranceEstimated Value/Approximate BalanceLoan/Debt BalanceNotes and Other ReceivablesEstimated Value/Approximate BalanceLoan/Debt BalancePartnership and Business InterestsEstimated Value/Approximate BalanceLoan/Debt BalanceOil, Gas, Mineral and Water InterestsEstimated Value/Approximate BalanceLoan/Debt BalanceAnticipated Judgments (from suits)Estimated Value/Approximate BalanceLoan/Debt BalanceAnticipated Judgments (from suits)Estimated Value/Approximate BalanceLoan/Debt BalanceOther AssetsEstimated Value/Approximate BalanceLoan/Debt BalanceAdditional DebtsPlease identify the total (estimated) amount owed on any debts, excluding any included above and consumer debts that are paid off each month:Total Amount Owed
