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TEN MINUTE QUESTIONNAIRE FOR

THE FAMILY TRUST SOLUTION

For Individuals

 

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:
Do you own any property in a land trust?
Do you have an umbrella insurance policy?
If yes, who is your insurance carrier?
What is your coverage limit? $
Are you subject to a divorce decree?
Are there any pending or threatened claims or suits against you?
Are you 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.)

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).

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 in the event you could not make them for yourself?
Please name a successor if the first person you choose cannot act.

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 anticipate an inheritance?
Have you ever lived in a community property state
(CA, WI, AZ, NM, TX, ETC.)?
Have you ever filed a gift tax return?
Are you a beneficiary of any trust?
Are you 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 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. Otherwise, the table will not work.

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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