Questionnaire (Couples)

Step 1 of 4

Your Information

Legal Name(Required)

Prefix First Middle Last Suffix

Nickname

Address(Required)

Street Address Address Line 2 City State / Province ZIP Code

Home Phone

Work Phone

Work Phone Extension

Cell Phone(Required)

Email(Required)

Date of Birth

Occupation

Job Title

Employer

Estimated Annual Income

Please enter a number from 0 to 99999999999.

Are you a U.S. citizen?(Required)

Yes

In what state are you domiciled?(Required)

Are you healthy?

Yes

Please explain:

Balance Sheet

THIS QUESTIONNAIRE IS INTENDED TO SUPPLY OVERVIEW INFORMATION ONLY.
REMINDER: Bring your existing estate planning documents, if available.

NOTE: Scroll sideways as needed to view additional fields.

Name

Person 1 Name(Required)

Person 2 Name(Required)

Assets

Please do not include "$" signs, commas, or cents.

Person 1

Person 2

Joint

Subtotal

Home

Person 1 Home(Required)

Please enter a number from 0 to 99999999999.

Person 2 Home(Required)

Please enter a number from 0 to 99999999999.

Joint Home(Required)

Please enter a number from 0 to 99999999999.

Home Subtotal(Required)

Other Real Estate

Person 1 Other Real Estate(Required)

Please enter a number from 0 to 99999999999.

Person 2 Other Real Estate(Required)

Please enter a number from 0 to 99999999999.

Joint Other Real Estate(Required)

Please enter a number from 0 to 99999999999.

Other Real Estate Subtotal(Required)

Stocks, Bonds

Person 1 Stocks, Bonds(Required)

Please enter a number from 0 to 99999999999.

Person 2 Stocks, Bonds(Required)

Please enter a number from 0 to 99999999999.

Joint Stocks, Bonds(Required)

Please enter a number from 0 to 99999999999.

Stocks, Bonds Subtotal(Required)

401(k), Keogh, etc.

Person 1 401(k), Keogh, etc.(Required)

Please enter a number from 0 to 99999999999.

Person 2 401(k), Keogh, etc.(Required)

Please enter a number from 0 to 99999999999.

401(k), Keogh, etc. Subtotal(Required)

IRA

Person 1 IRA(Required)

Please enter a number from 0 to 99999999999.

Person 2 IRA(Required)

Please enter a number from 0 to 99999999999.

IRA Subtotal(Required)

Roth IRA

Person 1 Roth IRA(Required)

Please enter a number from 0 to 99999999999.

Person 2 Roth IRA(Required)

Please enter a number from 0 to 99999999999.

Roth IRA Subtotal(Required)

Private Placements

Person 1 Private Placements(Required)

Please enter a number from 0 to 99999999999.

Person 2 Private Placements(Required)

Please enter a number from 0 to 99999999999.

Joint Private Placements(Required)

Please enter a number from 0 to 99999999999.

Private Placements Subtotal(Required)

Cash

Person 1 Cash(Required)

Please enter a number from 0 to 99999999999.

Person 2 Cash(Required)

Please enter a number from 0 to 99999999999.

Joint Cash(Required)

Please enter a number from 0 to 99999999999.

Cash Subtotal(Required)

Insurance - Death Benefit

Person 1 Insurance - Death Benefit(Required)

Please enter a number from 0 to 99999999999.

Person 2 Insurance - Death Benefit(Required)

Please enter a number from 0 to 99999999999.

Joint Insurance - Death Benefit(Required)

Please enter a number from 0 to 99999999999.

Insurance - Death Benefit Subtotal(Required)

Business Interests

Person 1 Business Interests(Required)

Please enter a number from 0 to 99999999999.

Person 2 Business Interests(Required)

Please enter a number from 0 to 99999999999.

Joint Business Interests(Required)

Please enter a number from 0 to 99999999999.

Business Interests Subtotal(Required)

Notes Receivable

Person 1 Notes Receivable(Required)

Please enter a number from 0 to 99999999999.

Person 2 Notes Receivable(Required)

Please enter a number from 0 to 99999999999.

Joint Notes Receivable(Required)

Please enter a number from 0 to 99999999999.

Notes Receivable Subtotal(Required)

Other

Person 1 Other Assets(Required)

Please enter a number from 0 to 99999999999.

Person 2 Other Assets(Required)

Please enter a number from 0 to 99999999999.

Joint Other Assets(Required)

Please enter a number from 0 to 99999999999.

Other Assets Subtotal(Required)

Total Assets

Person 1 Total Assets(Required)

Person 2 Total Assets(Required)

Joint Total Assets(Required)

Grand Total Assets(Required)

Liabilities

Please do not include "$" signs, commas, or cents.

Person 1

Person 2

Joint

Subtotal

Debts

Person 1 Debts(Required)

Please enter a number from 0 to 99999999999.

Person 2 Debts(Required)

Please enter a number from 0 to 99999999999.

Joint Debts(Required)

Please enter a number from 0 to 99999999999.

Debts Subtotal(Required)

Mortgage(s) on Home

Person 1 Mortgage(s) on Home(Required)

Please enter a number from 0 to 99999999999.

Person 2 Mortgage(s) on Home(Required)

Please enter a number from 0 to 99999999999.

Joint Mortgage(s) on Home(Required)

Please enter a number from 0 to 99999999999.

Mortgage(s) on Home Subtotal(Required)

Other

Person 1 Other Liabilities(Required)

Please enter a number from 0 to 99999999999.

Person 2 Other Liabilities(Required)

Please enter a number from 0 to 99999999999.

Joint Other Liabilities(Required)

Please enter a number from 0 to 99999999999.

Other Liabilities Subtotal(Required)

Total Liabilities

Person 1 Total Liabilities(Required)

Person 2 Total Liabilities(Required)

Joint Total Liabilities(Required)

Grand Total Liabilities(Required)

How did you learn of us?(Required)

Acknowledgement(Required)

I have reviewed this form, and I am ready to submit. I understand that an attorney/client relationship is not created by submitting the questionnaire.

Name

This field is for validation purposes and should be left unchanged.

Your Information

Your Partner's Information

Additional Information

Balance Sheet

Assets

Liabilities