CONFIDENTIAL ESTATE PLANNING QUESTIONNAIRE

                                                                                      FOR: 



Your full name ______________________________



AND



Spouse's full name __________________________________


CONTACT INFORMATION

Residence (street address) ___________________________

City, state, zip ___________________________

County (of residence) ___________________________

Home phone ___________________________

Your employer's name ___________________________

Your business phone number ___________________________

Spouse's employer's name ___________________________

Spouse's business phone number ___________________________

What number would you like us to use to contact you during the day? ________________ 

Date prepared ______________________


Prepared for: J. Michael Haskin, P. A., 100 E. Park, Suite 203, P. O. Box 413, Olathe, KS 66051-0413 

Phone (913) 782-0706, Fax (913) 782-1014, E-mail haskinlawoffice@gmail.com


The information contained in this questionnaire is attorney-privileged and confidential information

prepared for and intended only for the use of the attorney named above. Any dissemination,

distribution, or copying of this information is strictly prohibited.


YOUR PERSONAL INFORMATION


Your name as signed on legal documents _______________________________________

Your social security number _______________________________________

Your date of birth _______________________________________

Are you a U. S. Citizen? Yes _____________ No _____________

Have you had prior marriages? Yes _____________ No _____________


SPOUSE'S PERSONAL INFORMATION


Spouse's name as signed on legal documents _______________________________________

Spouse's social security number _______________________________________

Spouse's date of birth _______________________________________

Is spouse a U. S. Citizen? Yes ____________ No _____________

Has spouse had prior marriages? Yes ____________ No _____________


ADDITIONAL ESTATE PLANNING QUESTIONS


Is there any person (other than a minor child) who is partially or wholly dependent upon you

for financial support or physical care?                                                                                                            Yes _________ No __________

Does any family member have a disability or require special attention?                                              Yes _________ No _______ ___

Do you have a comment or concern about the ability of a child or other beneficiary to responsibly handle an inheritance?

                                                                                                                                                                                  Yes _________ No __________

Have the two of you executed any contract before or after your marriage regarding the division of property between the two

of you ?   (If so please provide us with a copy of the agreement.)                                                          Yes _________ No __________

 Do either of you expect to receive a substantial inheritance from a family member in the foreseeable future?

                                                                                                                                                                                   Yes _________ No __________

Do you have any interest in making a gift to a charity, either during your lifetime with a retained income interest,

or outright at your death, or as a contingent beneficiary if a named beneficiary should die?           Yes _________ No __________

(If yes, list charity or charities here)



CHILDREN


CHILD 1: Name ______________________________________________

Date of birth __________________________________

 Child's parent(s) (check one): Both _______ You _______ Spouse ______

Is this child married? Yes ____________ No _____________

If yes, name of child's spouse ______________________________________________

Does this child have any children? Yes ____________ No _____________

(If yes, and you wish to designate them as beneficiaries, list names and birthdates)



CHILD 2: Name ______________________________________________

Date of birth ______________________________________________

Child's parent(s) (check one): Both _______ You_______ Spouse ______

Is this child married? Yes ____________ No _____________

If yes, name of child's spouse ______________________________________________

Does this child have any children? Yes ____________ No _____________

(If yes, and you wish to designate them as beneficiaries, list names and birthdates)



CHILD 3: Name ______________________________________________

Date of birth ______________________________________________

Child's parent(s) (check one): Both _______ You______ Spouse ______

Is this child married? Yes ____________ No _____________

If yes, name of child's spouse ______________________________________________

Does this child have any children? Yes ____________ No _____________

(If yes, and you wish to designate them as beneficiaries, list names and birthdates)


PLEASE ADD ANOTHER SHEET FOR ADDITIONAL BENEFICIARIES


FINANCIAL INFORMATION


1. REAL ESTATE:


RESIDENCE Owner                                   (circle one)   You      Spouse     Joint         Value $____________

Less mortgage with ____________________________________________ (____________)

                                                                                                                                         Net Equity $____________


2. OTHER REAL ESTATE                                                   You       Spouse     Joint          Value $____________

(Give address or brief legal description) _________________________________________

Less mortgage with ____________________________________________ (____________)

                                                                                                                                         Net Equity $____________

(Please provide us with copies of deeds for all real estate.)


3. INVESTMENT BROKER ACCOUNTS (list name of broker and value of account)


________________________________________   You  Spouse   Joint                $____________ ________________________________________   You   Spouse  Joint               $____________ ________________________________________   You   Spouse  Joint                $____________

                                                                                                                    Total Broker Accounts $____________

(Please provide us with copies of your most recent statements.)


4. PUBLICLY TRADED STOCKS (list number of shares and name of company)

(These are stocks for which you hold the stock certificates. Do not include stock held in a brokerage account

which should be listed under “Investment Broker Accounts.”)

_____ shs. of ____________________________      You     Spouse  Joint                  $____________

_____ shs. of ____________________________      You     Spouse  Joint                  $____________

_____ shs. of _____________________________    You     Spouse  Joint                 $____________

                                                                                                                                         Total Stocks $____________


5. BONDS (list total values only)


U. S. Gov't Bonds (face value)                                                      You     Spouse        Joint           $____________

Municipal, Corporate or Other Bonds                                        You      Spouse        Joint          $____________

                                                                                                                                           Total Bonds $____________


6. BANK ACCOUNTS (list name of financial institution and average balance)


Checking ___________________________________            You   Spouse   Joint       $____________

Checking ______________________________ _____           You   Spouse   Joint       $____________

Money Market _______________________________            You   Spouse   Joint       $____________

Savings ____________________________________            You   Spouse   Joint       $____________

Certificate of Deposit _________________________                You   Spouse   Joint       $____________

Certificate of Deposit _________________________                You   Spouse  Joint        $____________

Other ______________________________ ______                You   Spouse  Joint       $____________

                                                                                                                                Total Bank Accounts $____________

(Please provide us with copies of your most recent statements.)


7. MORTGAGES OR NOTES THAT OTHERS OWE TO YOU

(list name of debtor and amount owed, and provide us with a copy.)

____________________________________________          You   Spouse   Joint         $___________ ____________________________________________           You   Spouse   Joint        $___________

                                                                                                                                                      Total Notes $___________


8. BUSINESS INTERESTS (If you own all or a part of a closely-held business, list here)

Name of Business ______________________________                 You  Spouse  Joint       $____________ 

Business type (circle one):     C Corp.       S Corp.      Partnership       Ltd. Liability Co.       Sole Prop.

Is there a buy-sell agreement for this business? Yes _______ No ________

(If yes, please furnish copy of agreement.)


9. ESTIMATED VALUE OF ALL MOTOR VEHICLES AND OTHER PERSONAL PROPERTY                $___________

Do you own any antiques, collectibles, or jewelry of great value?                          Yes_____ No______

If so, list them here:


10. YOUR RETIREMENT PLANS:  To list the type of plan, please use “PEN” (for Pension),”PS” (for profit-sharing),

“IRA” (for regular IRA's), “Roth” (for Roth IRA's), “401k,” 'KPERS” or “Other.”

Employer or trustee name                                Type                 Beneficiary                                                      Value

______________________________ ______ ______________                                      $_____________ ______________________________ ______ ______________                                      $_____________ ______________________________ ______ ______________                                      $_____________ ______________________________ ______ ______________                                      $_____________

                                                                                                                 Total of Your Retirement Plans $_____________


11. SPOUSE'S RETIREMENT PLANS To list the type of plan, please use “PEN” (for Pension),”PS” (for profit-sharing),

“IRA” (for regular IRA's), “Roth” (for Roth IRA's), “401k,' “KPERS” or “Other.”

Employer or trustee name                                      Type             Beneficiary                                                        Value

______________________________ ______ _____________                                             $_____________ ______________________________ ______ _____________                                             $_____________ ______________________________ ______ _____________                                             $_____________ ______________________________ ______ _____________                                              $_____________

                                                                                                               Total of Spouse's Retirement Plans $_____________


12. YOUR LIFE INSURANCE POLICIES

Life Insurance Policy #1 (list name of company and policy number)

___________________________________________________________________

Type of Policy * _____________________ Policy Owner _________________________

Primary Benef. ______________________                                                                    Death Value $___________


Life Insurance Policy #2 (list name of company and policy number) ____________________________________________________________________

Type of Policy * _____________________ Policy Owner _________________________

Primary Benef. ______________________                                                                    Death Value $_____________


Life Insurance Policy #3 (list name of company and policy number) ______________________________________________________________________

 Type of Policy * _____________________ Policy Owner _________________________

Primary Benef. ______________________                                                                      Death Value $______________

                                                                                                         Total Death Value of Your Life Insurance $______________


*For type of policy, please say whether policy is “term,” “whole life,” “universal life," "group life," or “split-dollar.”


13. SPOUSE'S LIFE INSURANCE POLICIES


Life Insurance Policy #1 (list name of company and policy number) ______________________________________________________________________

Type of Policy * _____________________ Policy Owner _________________________

Primary Benef. ______________________                                                                          Death Value $__________


Life Insurance Policy #2 (list name of company and policy number) _______________________________________________________________________

Type of Policy * _____________________ Policy Owner _________________________

Primary Benef. ______________________                                                                           Death Value $__________


Life Insurance Policy #3 (list name of company and policy number) _______________________________________________________________________

Type of Policy * _____________________ Policy Owner _________________________

Primary Benef. ______________________                                                                              Death Value $__________ 

                                                                                                          Total Death Value of Spouse's Life Insurance $__________


*For type of policy, please say whether policy is “term,” “whole life,” “universal life," "group life," or “split-dollar.”



                                    RECAP OF FINANCIAL INFORMATION


                      Asset                                                                            Value

1. Residence (equity)                                                              $__________

2. Total value other real estate (equity only)                  $__________

3. Total value investment broker accounts                       $__________

4. Total value publicly traded stocks                                  $__________

5. Total value bonds                                                                $__________

6. Total value bank accounts                                                 $__________

7. Total value mortgages or notes payable to you           $__________

8. Total value business interests (equity only)                 $__________

9. Total value motor vehicles and personal property     $__________ 

10. Total value of your retirement plans                            $__________

11. Total value of spouse's retirement plans                     $__________

12. Total value of your life insurance (death value)         $__________ 

13. Total value of spouse's life insurance (death value) $__________

                                                                 Total Estate Values $__________


Thank you for completing this estate planning questionnaire.