APPENDIX G

Estate-Planning Questionnaire for Married Couples

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A. GENERAL INFORMATION:

________
_____________

_______________________________________
____________________________________________________________________________________________________________
___________________________________________________________
AG
C. SEC. NO.
DA
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SOC.
BIRTH DATE & AGE
DATE
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____________________________________________________________________________________________________________
___________________________________________________________________________
(
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SOC. SEC. NO.
BIRTH D
DATE & AGE

_____________________________________________________________________
_________________________________________________________________________
____________________________________________________________________________________________________________
TELEPH
STREET ADDRESS
HOME TELEPHONE
D
DATE & PLACE OF MARRIAGE

____________________________________
____________________________________________________
____________________________________________________________________________________________________________
CITY/STAT
CITY/STATE
HOME/BUS
ZIP
HOME/BUSINESS
PHONE NOS.
FAX NO. & EMAIL ADDRESS, IF ANY

&+,/'5
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ADDRESS

SOC. SEC. NO.

AGE & BIRTH DATE

____________________________________________________________________________________________
______

____________________________________________________________________________________________

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____________________________________________________________________________________________
__________________

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process of adoption indicate with letter [A]. Indicate nonmarital children with letterr [N].)

ESIRED CHARITABLE GIFTS)

B. OTHER BENEFICIARIES: (INCLUDING
INCLUDING DESIRED
NAME

ADDRESS
S

RELATIONSHIP, IF ANY

AMOUNT

______________________________________
____________________________________________________________________________________________
_________________________________________________________________

_____________________________________________
____________________________________________________________________________________________
_________________________________________________________________
________________________________________________
____________________________________________________________________________________________
_____________________________________________________________

C. PRIOR MARRIAGES: If husband or wife have previously married, describe any

und the divorce decree (supply copy if available).
continuingg obligation under

__________
__________________________________________________________________________________________
________________________

__________________________________________________________________________________________
___________
__________________________________________________________________________________________

D. DOMICILE: If your employment, vacation or other demands require that you spend more
than a nominal amount of time in another state or country, you may be deemed a domiciliary of
that jurisdiction for estate tax purposes. If you feel that the question may apply to you, set forth
immediately below the name of the state or country, dates you were or will be present
in such
pre
jurisdiction, where you vote, register your automobile and propertyy owned in such jurisdiction.
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____________________________________________________________________________________________
___________________________________

__________________________________
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LANEOUS (If applicable, give details below

be
E. MISCELLANEOUS:
or on an
another sheet)

S
Y

N 1.

Have you or your spouse made any lifetime gifts eexceeding

[$13,000] per year to any
ex
,I
person or created any trust? ,I\HVSOHDVHVX
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N 2.

spo
Do you or your spouse
have a pow
power of appointment or other interests under a Will or
anot
Trust of another
person? ,
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availabl
available.)

3
N 3.

If you or your
spouse have any prospective inheritances, give source and estimated
y
amount.
amo

N 4.

If you or your spouse are or were employed, give details of any pension plans or
other employee benefits, including retained group health insurance, to which you are or
may be entitled.

N 5.

ve deta
If you or your spouse are self-employed or a member of a partnership, give
details of
rement, as wel
any contract or commitments to sell such interest at death or retirement,
well as
y
any retirement plans or other benefits that will be payable by reason of your
death. (If
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N 6.

tion, give details of any

ely held corporation,
If you or your spouse own stock in a closely
ck options, salary continuation or other
stock redemption agreements, stock
cable to you. ,I
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at may be applicable
deferred-compensation plans that
copies of documents.)

N 7.

deposit box? (If so,, please indicate bank and box number.)
Is there a safe-deposit

N 8.

fessional tax preparer? (If so, please indicate

indic
name, addr
Do you use a professional
address and
telephone number.)

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N 9.

10.

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long-ter care insurance? Are you

Do you maintain private health insurance and/or long-term
ested in long-term care insurance?
interested

Indicate below the person(s) or institution you wish to appoint (if applicable) as your
trust ; and (c) gua
executor; (b) trustee;
trustee
(a) executor;
guardian of any minor children. Often, a surviving
named as primar
spouse will be na
primary executor and is automatically guardian.

______________
_______________________________
tended Execu
Intended
Executor(s)

_______________________________
Intended Alternate Executor(s)

_______________________________
Intended Trustee(s)

_______________________________
Intended Alternate Trustee(s)

_______________________________
Guardian(s)

_______________________________
Alternate Guardian(s)

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F. CITIZENSHIP: If either spouse is a noncitizen of the United

nited States, pleas
please note the
country of citizenship below:

________________________
____________________________________________________________________________________________
____________________________________________

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G. ASSETS: (ESTIMATED CURRENT MARKET VALUE)

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1. Real estate: residence

a
S

dicate
Vacation home (please indicate
state
ate where situated)

indica
Other real estate (please indicate
state where situated)

tocks and mutual

mutua funds
2. Stocks
(non--IRA)
I
(non-IRA)
(non

3. Bonds and notes (including Series

EE/HH
bonds)
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4. Value of business assets if

self-employed or interested in
partnership or closely held
corporation

5. Savings accounts, savings

certificates, savings bonds, money
market and cash

a
S

6. Expected from otherr estates or

trusts

7. Interest in profit sharing,

retirement plans, Keogh plans or
uitiesa
annuities
8. IRA accountsb

9. Autos,
Autos, furniture, jewelry, art,
collections
ollections and household items
(conservative estimate)

10. Miscellaneous other assets

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TOTAL ASSETS

LESS MORTGAGES, LOANS

AND OTHER LIABILITIES

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LIFE INSURANCE DEATH BENEFITS FROM NEXT PAGE:

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a.

Please confirm all primary/contingent beneficiary designations for retirement/Keogh

tirement/Keog plans &
annuities.

b.

ns for all IRA accounts.

Please confirm all primary/contingent beneficiary designations
esignations

LIFE INSURANCE
NSURANCE

ing policies/contracts for review)

revie
000, please bring
(If more than $300,000,

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TOTALS
OTALS
: