Simplified Estate Planning Questionnaire

Your Name *

First Name

Last Name

Preferred Phone Number *

(###)

###

####

Check all that apply

I am legally married

I was previously married

I am single

Spouse's Name

First Name

Last Name

Spouse's Phone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have a Pre or Post Nuptial Agreement?(If Applicable)

Yes

No

Do you have over $150,000 in liquid assets? (Exclude your house and vehicle)

Yes

No

Are your total assets over $1,000,000?

Yes

No

Are your total assets over $5,000,000?

Yes

No

Are you (and your spouse, if married) a U.S. Citizen?

Yes - I am a U.S. Citizen and if I'm married, so is my spouse

No

Are you or your spouse a Veteran?

Yes - Self

Yes - Spouse

Both

Neither

Employment Status (Self)

Currently Employed

Retired

Disabled

Employment Status (Spouse)

Currently Employed

Retired

Disabled

Do any of your children have special needs, are on Medicaid, or receive SSI?

Yes

No

Check all that apply (for you or your spouse)

I am ill or have recently received a diagnosis

My spouse is ill or has recently received a diagnosis

I need a caregiver to provide support to me or my spouse

I am concerned about my ability to pay for long-term care now or in the future

I am interested in asset protection options

I would like to know more about trusts

My immediate family does not get along

I own a company or have an interest in a business

I own more than 1 property

I own more than 4 properties

I have an IRA or other retirement account