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 AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
E-mail Address:
Home Phone:
Cell Phone:
Date of Birth:
Social Security Number:
Are you?
U.S. citizenmilitary veteran
List any years of wartime service:
Occupation:
Retired?
Yes
Is your health?
goodfairpoor
Describe any health issues:
Do you have any mental capacity issues that may prevent signing documents?
YesNo
Current Marital Status:
MarriedWidowedDivorcedSeparatedSingle
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. citizenmilitary veteran
List any years of wartime service:
Occupation:
Retired?
Yes
Is Spouse’s health?
goodfairpoor
Describe any health issues:
Does Spouse have any mental capacity issues that may prevent signing documents?
YesNo
Do you have a pre-marital or post-marital agreement?
YesNo
If so, please attach a copy.
Did either you or your spouse have a previous marriage?
YesNo
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?
YesNo
If so, please attach a copy.

Part Two: Children & Family Information
1. Child’s Full Name:
Date of Birth:
Child’s Parent(s):
OursYoursSpouse’s
Child’s sex:
MF
Child’s Marital Status:
Home Address:
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
E-mail Address:
Home Phone:
Cell Phone:
Are you concerned about this child’s ability to manage money?
YesNo
Does this child have potential issues involving disability, debt, or potential divorce?
YesNo
Does this child have children of their own?
YesNo
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):
OursYoursSpouse’s
Child’s sex:
MF
Child’s Marital Status:
Home Address:
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
E-mail Address:
Home Phone:
Cell Phone:
Are you concerned about this child’s ability to manage money?
YesNo
Does this child have potential issues involving disability, debt, or potential divorce?
YesNo
Does this child have children of their own?
YesNo
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):
OursYoursSpouse’s
Child’s sex:
MF
Child’s Marital Status:
Home Address:
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
E-mail Address:
Home Phone:
Cell Phone:
Are you concerned about this child’s ability to manage money?
YesNo
Does this child have potential issues involving disability, debt, or potential divorce?
YesNo
Does this child have children of their own?
YesNo
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):
OursYoursSpouse’s
Child’s sex:
MF
Child’s Marital Status:
Home Address:
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
E-mail Address:
Home Phone:
Cell Phone:
Are you concerned about this child’s ability to manage money?
YesNo
Does this child have potential issues involving disability, debt, or potential divorce?
YesNo
Does this child have children of their own?
YesNo
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
WholeTerm
Death Benefit
Primary Beneficiary
Check box if Spouse
Spouse
Box 2 LIFE INSURANCE
Name of Account Owner
Insurance Company
Policy Type
WholeTerm
Death Benefit
Primary Beneficiary
Check box if Spouse
Spouse
Box 3 LIFE INSURANCE
Name of Account Owner
Insurance Company
Policy Type
WholeTerm
Death Benefit
Primary Beneficiary
Check box if Spouse
Spouse
Box 4 LIFE INSURANCE
Name of Account Owner
Insurance Company
Policy Type
WholeTerm
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?
YesNo
Current Payments?
Primary Beneficiary
Check box if Spouse
Spouse
Box 2 ANNUITIES
Owner/ Annuitant
Company
Retirement / Qualified?
YesNo
Current Payments?
Primary Beneficiary
Check box if Spouse
Spouse
Box 3 ANNUITIES
Owner/ Annuitant
Company
Retirement / Qualified?
YesNo
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?
YesNo
If so, please describe:
OTHER INTERESTS & CONSIDERATIONS
BUSINESS:
Do you own a business or operate as a sole proprietor?
YesNo
If so, name of business:
If so, do you have a formal business succession plan in place?
YesNo
PRENEED:
Have you purchased pre-paid burial contracts?
YesNo
If so, please describe:
TRUSTS:
Are you a beneficiary or a trustee under any trust?
YesNo
If so, please describe:
Are you expecting an inheritance?
YesNo
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?
YesNo
If so, please describe:
TRANSFERS:
In the past five years, have you made a gift worth more than $5,000?
YesNo
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?
YesNo
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:
UnsatisfiedSatisfiedVery Satisfied
Financial Advisor:
Level of satisfaction:
UnsatisfiedSatisfiedVery Satisfied
Legal Advisor:
Level of satisfaction:
UnsatisfiedSatisfiedVery Satisfied
Real Estate Agent:
Level of satisfaction:
UnsatisfiedSatisfiedVery Satisfied
Other:
Level of satisfaction:
UnsatisfiedSatisfiedVery Satisfied
LEGAL DOCUMENTS:
Which legal documents do you currently have in place?
General Durable Power of Attorney
SelfSpouse
Year Created
Healthcare Power of Attorney
SelfSpouse
Year Created
HIPAA Release Authorization
SelfSpouse
Year Created
Living Will (Desire for Natural Death)
SelfSpouse
Year Created
Last Will and Testament
SelfSpouse
Year Created
Revocable Living Trust
SelfSpouse
Year Created
Irrevocable Trust
SelfSpouse
Year Created
What are your main goals in creating or upgrading your estate plan? (Check all that apply)
Preserve my current Quality of LifeEnsure I’ll be well taken care of if I become disabledAvoid 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 inheritanceEnsure my loved ones receive a good educationProvide 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?
AntiquesExercisePuzzles & GamesTennisArts & CraftsFishingReadingTravelingCollectingGardeningSewingComputersGolfShoppingCookingPhotographySports
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 AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone
Preferred Contact Method:
Cell PhoneHome PhoneE-mail

Verification
Please enter any two digits *Example: 12
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