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TEN MINUTE QUESTIONNAIRE FOR

THE FAMILY TRUST SOLUTION

For Couples

 

If you would like to print out the form and then fax it, please use the
print version of the form. If question does not apply to you, please type "DNA" (does not apply).

 
Your Full Legal Name:
Your Nickname, if any:
Your Address:

City:

State:

ZIP Code:

Home Phone:
Work Phone: (including extension)
Cell Phone:
Your Email:

Your Date of Birth (mm/dd/yyyy):

Your Occupation:
Your Job Title:
Your Employer:
Estimated Annual Income: $
Are you a U.S. citizen?
In what state are you domiciled?
Are you healthy?
  If not, please explain:
 
 
Spouse's Full Legal Name:
Spouse's Nickname, if any:
Spouse's Work Phone:
(including extension)
Spouse's Cell Phone:
Spouse's Email:
Spouse's Date of Birth:
Spouse's Occupation:
Spouse's Job Title:
Spouse's Employer:
Spouse's Estimated Annual Income: $
Is your spouse a U.S. citizen?
In what state is your spouse domiciled?
Is your spouse healthy?
  If not, please explain:
Do either of you own any property in a land trust?
Do you have a pre-nuptial agreement?
Do you have an umbrella insurance policy?
If yes, who is your insurance carrier?
What is your coverage limit?  $
Are you or your spouse subject to a divorce decree?
Are there any pending or threatened claims or suits against you or your spouse?
Are you or your spouse a trustee, director, fiduciary, or retirement/investment plan administrator?
Other than tax savings, what are your estate planning goals?
Where is your safe deposit box located?
(Leave blank if not applicable.)
Is this a first marriage for both spouses?

Please enter your children's full legal names, dates of birth, health status, marital status, and number of descendants.
If this question does not apply to you, please type "DNA" (Does Not Apply).

Please enter your spouse's children's full legal names, dates of birth, health status, marital status, and number of descendants.
If this question does not apply to you, please type "DNA" (Does Not Apply).

If you have minor children, who would act as their guardian if you could not?
(Also, please name a successor guardian if you can.)

Who would make medical decisions for you and your spouse in the event you could not make them for yourselves?
Please name a successor if the first person you choose cannot act.

You:

Your spouse:

Where would you have your assets go in the event of a catastrophe in which your nuclear family was lost?

Specify details below:

Do you or your spouse anticipate an inheritance?
Have you or your spouse ever lived in a community property state
(CA, WI, AZ, NM, TX, ETC.)?
Have you or your spouse ever filed a gift tax return?
Are you or your spouse a beneficiary of any trust?
Are you or your spouse charitably inclined?

If so, please elaborate:

What is the name and phone number of your accountant?

What is the name and phone number of your financial advisor, and for what institution does he/she work?

Do you or your spouse know of any other clients of Harrison & Held, LLP?

 

THIS QUESTIONNAIRE IS INTENDED TO SUPPLY OVERVIEW INFORMATION ONLY.
Your information will be used only by Harrison & Held.

REMINDER: Bring your existing estate planning documents, if available.

BALANCE SHEET

Please do not include "$" signs or commas.

SPOUSE A SPOUSE B JOINT
Home

$

$

$

Other Real Estate

$

$

$

Stocks, Bonds

$

$

$

401(k), Keogh, etc.

$

$

IRA

$

$

Roth IRA

$

$

Private Placements

$

$

$

Cash

$

$

$

Insurance - Death Benefit

$

$

$

Business Interests

$

$

$

Notes Receivable

$

$

$

Other

$

$

$

 
 
Debts

$

$

$

Mortgage(s) on Home

$

$

$

Other

$

$

$

 
How did you learn of us?

If you would like to print out the form and then fax it, please use the
print version of the form.

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