Estate Planning and Elder Law Questionnaire - Full Form

"*" indicates required fields

1Personal Info

2Spouse

3Family

4Income

5Assets

6Healthcare & LTC

7Estate Planning

8Additional Info

9Consent & Authorization

Personal Information

If you are completing this form on behalf of someone else, please provide their information in this Questionnaire, rather than your own.

Full Legal Name*

Current Residential Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

MM slash DD slash YYYY

Phone Number*

Email Address*

Marital Status*

Single

Married

Divorced

Widowed

Date of Divorce

MM slash DD slash YYYY

Date of Spouse's Passing

MM slash DD slash YYYY

Spouse's Personal Information (if applicable)

Spouse's Full Legal Name

Spouse's Date of Birth

MM slash DD slash YYYY

Spouse's Phone Number

Spouse's Email Address

Spouse's Previous Marital Status

None

Prior Divorce

Date of Divorce

MM slash DD slash YYYY

Family Information

Children / Stepchildren / Dependents

Please provide details for each child

Name

Date of Birth

Contact Info

Child of Both? (Y/N)

Child of Spouse? (Y/N)

Do any of the following apply to any of the above individuals?

Drug/alcohol dependency

Medicaid

SSI

Bankruptcy

Please identify the individual and explain:

Income Overview

Annual Income

Less than $25,000

$25,000 - $50,000

$50,000 - $100,000

Over $100,000

Primary Sources of Income

Check all that apply

Social Security

Pension

Retirement Accounts

Employment

Other (specify)

Social Security Amount

Other Income Source (please specify)

Spouse's Annual Income

Less than $25,000

$25,000 - $50,000

$50,000 - $100,000

Over $100,000

Spouse's Primary Sources of Income

Check all that apply

Social Security

Pension

Retirement Accounts

Employment

Other (specify)

Spouse's Social Security Amount

Other Income Source (please specify)

Asset Information

Real Estate

Primary Residence Address

Value

Joint?

With Spouse

With Another

Additional Properties

Address

Value

Joint? (No / With Spouse / With Another)

Financial Assets

Checking Accounts

Financial Institution

Account No.

Beneficiary Designations

Owner(s)

Value

Savings Accounts

Financial Institution

Account No.

Beneficiary Designations

Owner(s)

Value

Investment Accounts

Financial Institution

Account No.

Beneficiary Designations

Owner(s)

Value

Retirement Accounts

Financial Institution

Account No.

Beneficiary Designations

Owner(s)

Value

Spouse's Retirement Accounts

Financial Institution

Account No.

Beneficiary Designations

Owner(s)

Value

Life Insurance Policies

Financial Institution

Account No.

Beneficiary Designations

Owner(s)

Value

Spouse's Life Insurance Policies

Financial Institution

Account No.

Beneficiary Designations

Owner(s)

Value

Personal Property

Vehicles

Vehicle

Value

Valuable Personal Items

Item

Value

Healthcare and Long-Term Care Planning

Current Health Status

Significant Medical Conditions

Spouse's Current Health Status

Spouse's Significant Medical Conditions

Long-Term Care Preferences

Remain at Home

Assisted Living

Nursing Home

Other preferences

None

Other preferences

Long-Term Care Insurance

Yes

Considering

Insurance Company and Benefit Amount

Estate Planning Goals

Primary Estate Planning Objectives

Check all that apply

Minimize Estate Taxes

Provide for Family / Dependents

Charitable Giving

Medicaid / Asset Protection from Long Term Care Costs

Other Goals

None

Other Goals

Existing Estate Planning Documents*

Check all that apply

Will

Living Trust

Power of Attorney

Healthcare Directive

None

Medicaid and Benefits Planning

Anticipated Need for Medicaid for Long Term Care

Immediate

Potential Future Need

Not Anticipated

Current Government Benefits

Check all that apply

Social Security

Medicare

Medicaid

Veteran's Benefits

Other

N/A

Other Government Benefits

Decision-Makers in Case of Disability

Preferred Financial Power of Attorney

Primary Agent

Alternate Agent

Preferred Healthcare Power of Attorney

Primary Agent

Alternate Agent

Additional Estate Planning Considerations

Prenuptial or Post-nuptial Agreement:

Yes

Considering

Wish to Leave Everything to Spouse:

Yes

No (Explain)

Explanation

Wish to Leave Everything to Children in Equal Shares:

Yes

No (Explain)

Explanation

If Child Predeceases, Distribution Preference:

Their Surviving Children

Their Spouse

Surviving Siblings

Other (Explain)

Explanation

Leave Estate to Beneficiaries Under 18

Yes

Considering

Concerns About Leaving Money Outright

Yes

Considering

Preferred Guardian for Minor Children:

Primary Guardian

Alternate Guardian

Preferred Executor of Last Will & Testament:

Primary Executor

Alternate Executor

Preferred Trustee for Children/Grandchildren's Inheritance:

Primary Trustee

Alternate Trustee

Additional Information

Specific Family Dynamics or Concerns

Philanthropic Interests / Charitable Organizations of Interest

Additional Comments or Specific Instructions

Consent and Authorization

I authorize the law firm to use the information provided in this questionnaire for developing a comprehensive elder law and estate planning strategy.

Signature*

Date*

MM slash DD slash YYYY

Note: All information will be kept strictly confidential and is protected by attorney-client privilege.