Estate Questionnaire

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 may

Husband 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 Questions

Have 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

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

Date Range

Have you or your spouse ever been divorced or widowed?

Yes
No

Name

First Last

Date

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.

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:

Estate Questionnaire

Step 1 of 6

Husband Personal Information

Wife Personal Information

Children and Beneficiaries

Designated Persons

Additional Questions

Advisors

Asset Summary

Additional Debts