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Estate Planning
CLIENT QUESTIONNAIRE
Part One: Client Personal Information
Instructions
Thank you for trusting Four Pillars Law Firm to review your personal information. This information is confidential, and will be used to help our attorneys assess your legal planning needs. Please provide information that is as accurate and complete as possible so we may be able to offer our best legal advice concerning your situation.
First Name:
Last Name:
Nickname:
Home Address:
Street Address
Apt, Suite, Bldg. (optional)
City
State / Province / Region
Postal / Zip Code
Country
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d\'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palestinian Territory
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
E-mail Address:
Home Phone:
Cell Phone:
Date of Birth:
Social Security Number:
Are you:
U.S. citizen?
military veteran?
List any years of wartime service:
Occupation:
Retired?
Yes
Is your health:
good?
fair?
poor?
Describe any health issues:
Do you have any mental capacity issues that may prevent signing documents?
Yes
No
Current Marital Status:
Married
Widowed
Divorced
Separated
Single
Spouse
Spouse’s First Name:
Spouse’s First Name:
Nickname:
Marriage Date:
E-mail Address:
Home Phone:
Cell Phone:
Date of Birth:
Social Security Number:
Is Spouse:
U.S. citizen?
military veteran?
List any years of wartime service:
Occupation:
Retired?
Yes
Is Spouse’s health:
good?
fair?
poor?
Describe any health issues:
Does Spouse have any mental capacity issues that may prevent signing documents?
Yes
No
Do you have a pre-marital or post-marital agreement?
Yes
No
If so, please attach a copy.
Did either you or your spouse have a previous marriage?
Yes
No
If so, please attach details.
Do you have any legal obligations to a former spouse or child(ren) from a prior marriage under a separation agreement or divorce decree?
Yes
No
If so, please attach a copy.
Part Two: Children & Family Information
1. Child’s Full Name:
Date of Birth:
Child’s Parent(s):
Ours
Yours
Spouse’s
Child’s sex:
M
F
Child’s Marital Status:
Home Address:
Street Address
Apt, Suite, Bldg. (optional)
City
State / Province / Region
Postal / Zip Code
Country
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d\'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palestinian Territory
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
E-mail Address:
Home Phone:
Cell Phone:
Are you concerned about this child’s ability to manage money?
Yes
No
Does this child have potential issues involving disability, debt, or potential divorce?
Yes
No
Does this child have children of their own?
Yes
No
If yes, how many?
What age range?
Please explain any relevant notes concerning this child:
Child 2
2. Child’s Full Name:
Date of Birth:
Child’s Parent(s):
Ours
Yours
Spouse’s
Child’s sex:
M
F
Child’s Marital Status:
Home Address:
Street Address
Apt, Suite, Bldg. (optional)
City
State / Province / Region
Postal / Zip Code
Country
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d\'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palestinian Territory
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
E-mail Address:
Home Phone:
Cell Phone:
Are you concerned about this child’s ability to manage money?
Yes
No
Does this child have potential issues involving disability, debt, or potential divorce?
Yes
No
Does this child have children of their own?
Yes
No
If yes, how many?
What age range?
Please explain any relevant notes concerning this child:
Child 3
3. Child’s Full Name:
Date of Birth:
Child’s Parent(s):
Ours
Yours
Spouse’s
Child’s sex:
M
F
Child’s Marital Status:
Home Address:
Street Address
Apt, Suite, Bldg. (optional)
City
State / Province / Region
Postal / Zip Code
Country
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d\'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palestinian Territory
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
E-mail Address:
Home Phone:
Cell Phone:
Are you concerned about this child’s ability to manage money?
Yes
No
Does this child have potential issues involving disability, debt, or potential divorce?
Yes
No
Does this child have children of their own?
Yes
No
If yes, how many?
What age range?
Please explain any relevant notes concerning this child:
Child 4
4. Child’s Full Name:
Date of Birth:
Child’s Parent(s):
Ours
Yours
Spouse’s
Child’s sex:
M
F
Child’s Marital Status:
Home Address:
Street Address
Apt, Suite, Bldg. (optional)
City
State / Province / Region
Postal / Zip Code
Country
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d\'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palestinian Territory
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
E-mail Address:
Home Phone:
Cell Phone:
Are you concerned about this child’s ability to manage money?
Yes
No
Does this child have potential issues involving disability, debt, or potential divorce?
Yes
No
Does this child have children of their own?
Yes
No
If yes, how many?
What age range?
Please explain any relevant notes concerning this child:
Other Relevant Notes Concerning Potential Heirs
Do you have any children who have died leaving children of their own (i.e. your grandchildren)? If yes, please explain:
Please list any other family members or friends who you may want to leave part of your estate:
Full Name, Age, Relationship:
On a scale from 1 to 10, where 1 is Problematic and 10 is Cooperative, please rate how well you believe your potential heirs get along with each other:
On a scale from 1 to 10, where 1 is Problematic and 10 is Cooperative, please rate how well you believe your potential heirs get along with their spouses (if any):
Please describe any foreseeable problems or issues you feel may adversely affect any of your potential heirs or your estate plan:
Do you have any potential heirs with disabilities or special needs? If so, please explain:
Are any of your family members or intended beneficiaries qualified to receive governmental benefits as a result of any mental or physical impairment? If so, please explain:
Part Three: Financial Information
ASSETS
Cash, CDs & Bank Accts
Your Account
Spouse’s Account
Joint Account
Joint Account Holder Name
Check box if Spouse
Spouse
Stock, Bond & Mutual Fund
Your Account
Spouse’s Account
Joint Account
Joint Account Holder Name
Check box if Spouse
Spouse
Annuities (non-qualified)
Your Account
Spouse’s Account
Joint Account
Joint Account Holder Name
Check box if Spouse
Spouse
Notes & Accounts Receivable
Your Account
Spouse’s Account
Joint Account
Joint Account Holder Name
Check box if Spouse
Spouse
Residence
Your Account
Spouse’s Account
Joint Account
Joint Account Holder Name
Check box if Spouse
Spouse
Other Real Estate
Your Account
Spouse’s Account
Joint Account
Joint Account Holder Name
Check box if Spouse
Spouse
Life Insurance (cash value)
Your Account
Spouse’s Account
Joint Account
Joint Account Holder Name
Check box if Spouse
Spouse
IRA, 401(k)
Your Account
Spouse’s Account
Other Qualified Plan / Account
Your Account
Spouse’s Account
Other
Other
Your Account
Spouse’s Account
Joint Account
Joint Account Holder Name
Check box if Spouse
Spouse
Subtotals
Your Account Subtotal
Spouse’s Account Subtotal
Joint Account Subtotal
LIABILITIES
Real Estate Mortgages
Your Debt
Spouse’s Debt
Joint Debt
Joint Debtor Name
Check box if Spouse
Spouse
Insurance Policy Loans
Your Debt
Spouse’s Debt
Joint Debt
Joint Debtor Name
Check box if Spouse
Spouse
Other Loans and Notes
Your Debt
Spouse’s Debt
Joint Debt
Joint Debtor Name
Check box if Spouse
Spouse
Taxes
Your Debt
Spouse’s Debt
Joint Debt
Joint Debtor Name
Check box if Spouse
Spouse
Other
Other
Your Debt
Spouse’s Debt
Joint Debt
Joint Debtor Name
Check box if Spouse
Spouse
Subtotal
Your Debt Subtotal
Spouse’s Debt Subtotal
Joint Debt Subtotal
LIFE INSURANCE
Box 1 LIFE INSURANCE
Name of Account Owner
Insurance Company
Policy Type
Whole
Term
Death Benefit
Primary Beneficiary
Check box if Spouse
Spouse
Box 2 LIFE INSURANCE
Name of Account Owner
Insurance Company
Policy Type
Whole
Term
Death Benefit
Primary Beneficiary
Check box if Spouse
Spouse
Box 3 LIFE INSURANCE
Name of Account Owner
Insurance Company
Policy Type
Whole
Term
Death Benefit
Primary Beneficiary
Check box if Spouse
Spouse
Box 4 LIFE INSURANCE
Name of Account Owner
Insurance Company
Policy Type
Whole
Term
Death Benefit
Primary Beneficiary
Check box if Spouse
Spouse
IRA & RETIREMENT BENEFIT PLANS
Box 1 IRA & RETIREMENT BENEFIT PLANS
Name of Policyholder
Company
Type (i.e. traditional, Roth, simple, SEP)
Approximate Value
Primary Beneficiary
Check box if Spouse
Spouse
Box 2 IRA & RETIREMENT BENEFIT PLANS
Name of Policyholder
Company
Type (i.e. traditional, Roth, simple, SEP)
Approximate Value
Primary Beneficiary
Check box if Spouse
Spouse
Box 3 IRA & RETIREMENT BENEFIT PLANS
Name of Policyholder
Company
Type (i.e. traditional, Roth, simple, SEP)
Approximate Value
Primary Beneficiary
Check box if Spouse
Spouse
Box 4 IRA & RETIREMENT BENEFIT PLANS
Name of Policyholder
Company
Type (i.e. traditional, Roth, simple, SEP)
Approximate Value
Primary Beneficiary
Check box if Spouse
Spouse
ANNUITIES
Box 1 ANNUITIES
Owner/ Annuitant
Company
Retirement / Qualified?
Yes
No
Current Payments?
Primary Beneficiary
Check box if Spouse
Spouse
Box 2 ANNUITIES
Owner/ Annuitant
Company
Retirement / Qualified?
Yes
No
Current Payments?
Primary Beneficiary
Check box if Spouse
Spouse
Box 3 ANNUITIES
Owner/ Annuitant
Company
Retirement / Qualified?
Yes
No
Current Payments?
Primary Beneficiary
Check box if Spouse
Spouse
HEALTH INSURANCE
Box 1 HEALTH INSURANCE
Name of Insured
Health Insurance Company
Policy Type
Monthly Premium
Box 2 HEALTH INSURANCE
Name of Insured
Health Insurance Company
Policy Type
Monthly Premium
Box 3 HEALTH INSURANCE
Name of Insured
Health Insurance Company
Policy Type
Monthly Premium
Box 4 HEALTH INSURANCE
Name of Insured
Health Insurance Company
Policy Type
Monthly Premium
Have you purchased a long-term care insurance policy?
Yes
No
If so, please describe:
OTHER INTERESTS & CONSIDERATIONS
BUSINESS:
Do you own a business or operate as a sole proprietor?
Yes
No
If so, name of business:
If so, do you have a formal business succession plan in place?
Yes
No
PRENEED:
Have you purchased pre-paid burial contracts?
Yes
No
If so, please describe:
TRUSTS:
Are you a beneficiary or a trustee under any trust?
Yes
No
If so, please describe:
Are you expecting an inheritance?
Yes
No
If so, from whom?
Please list anticipated inheritance assets and estimated value:
MISCELLANEOUS:
Please list any other assets not previously listed:
EXPENSES:
Do you anticipate any major expenses?
Yes
No
If so, please describe:
TRANSFERS:
In the past five years, have you made a gift worth more than $5,000?
Yes
No
If so, please describe the nature, amount, time, and recipient of any gift(s):
Do you plan to sell or gift any substantial assets in the future?
Yes
No
If so, please describe:
Describe any other facts or matters about your affairs you think may be relevant in planning your estate but which are not covered by the above sections of the Questionnaire.
Part Four: Goals & Planning
ADVISORS:
Please provide the name of any current advisors and rate your level of satisfaction.
Accountant:
Level of satisfaction:
Unsatisfied
Satisfied
Very Satisfied
Financial Advisor:
Level of satisfaction:
Unsatisfied
Satisfied
Very Satisfied
Legal Advisor:
Level of satisfaction:
Unsatisfied
Satisfied
Very Satisfied
Real Estate Agent:
Level of satisfaction:
Unsatisfied
Satisfied
Very Satisfied
Other:
Level of satisfaction:
Unsatisfied
Satisfied
Very Satisfied
LEGAL DOCUMENTS:
Which legal documents do you currently have in place?
General Durable Power of Attorney
Self
Spouse
Year Created
Healthcare Power of Attorney
Self
Spouse
Year Created
HIPAA Release Authorization
Self
Spouse
Year Created
Living Will (Desire for Natural Death)
Self
Spouse
Year Created
Last Will and Testament
Self
Spouse
Year Created
Revocable Living Trust
Self
Spouse
Year Created
Irrevocable Trust
Self
Spouse
Year Created
What are your main goals in creating or upgrading your estate plan? (Check all that apply)
Preserve my current Quality of Life
Ensure I’ll be well taken care of if I become disabled
Avoid Probate (fees and Court oversight)
Ensure my loved ones’ inheritance is protected from lawsuits, divorces, etc.
Make sure my children receive my intended inheritance (while also providing for a second spouse)
Ensure my loved ones don’t squander their inheritance
Ensure my loved ones receive a good education
Provide support for a disabled heir (without jeopardizing their benefits)
Pass on my values (as well as my assets)
Preserve and continue a family business (such as a farm) or closely-held business
Describe any other specific objectives you wish your estate plan to accomplish:
Part Five: Background Information
What are your favorite hobbies?
Antiques
Exercise
Puzzles & Games
Tennis
Arts & Crafts
Fishing
Reading
Traveling
Collecting
Gardening
Sewing
Computers
Golf
Shopping
Cooking
Photography
Sports
Other hobbies?
Are you or your spouse an active member of any groups, clubs, or organizations?
Do you have pets?
How did you find out about Four Pillars?
Part Six: Information Certification
I certify...
I certify the statements and information provided on this questionnaire are true and accurate to the best of my knowledge and belief, after conducting a thorough inquiry. I understand any inaccuracies and/or omissions in the information provided may substantially impact the appropriateness of any recommended planning, which may result in the need for contracting additional and/or revised planning.
Section
Name of Prospective Client
Electronic Signature
Please type your First and Last Name
Date
ACCEPTANCE
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
OR
Contact Information for Person Completing the Questionnaire, if not the Prospective Client:
Section
Name of Person who completed this form
Electronic Signature
Date
ACCEPTANCE
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
Relationship to Prospective Client
E-mail Address
Address
Street Address
Apt, Suite, Bldg. (optional)
City
State / Province / Region
Postal / Zip Code
Country
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d\'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palestinian Territory
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
Phone
Preferred Contact Method:
Cell Phone
Home Phone
E-mail
Verification
Please enter any two digits
*
Example: 12
This box is for spam protection -
please leave it blank
:
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