CONFIDENTIAL ESTATE PLANNING QUESTIONNAIRE

FOR:


Your full name ______________________________

CONTACT INFORMATION: 

Residence (street address) ___________________________

City, state, zip ___________________________

County (of residence) ___________________________

Home phone ___________________________

Your employer's name ___________________________

Your 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 been married? Yes _____________ No _____________


ADDITIONAL ESTATE PLANNING QUESTIONS


Is there any person who is partially or wholly dependent upon you for financial support or physical care? Yes _________ No __________

Do you wish to name a beneficiary who has a disability or requires special attention? Yes ______ No _______

Do you have a comment or concern about the ability of a beneficiary to responsibly handle an inheritance? Yes _________ No __________

Do 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)


INDIVIDUAL BENEFICIARIES

BENEFICIARY 1: Name_____________________________________________

Date of birth _______________________________________

Relationship to you __________________________________

Is this beneficiary married? Yes ____________ No _____________

If yes, do you wish to designate the spouse as the alternate beneficiary if this beneficiary is deceased? Yes_____________ No _____________

Does this beneficiary have any children? Yes ____________ No ____________

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


BENEFICIARY 2:

Name ______________________________________________

Date of birth ______________________________________________ Relationship to you __________________________________

Is this beneficiary married? Yes ____________ No _____________

If yes, do you wish to designate the spouse as the alternate beneficiary if this beneficiary is deceased? Yes_____________ No _____________

Does this beneficiary have any children? Yes ________ No _________

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


BENEFICIARY 3:

Name ______________________________________________

Date of birth ______________________________________________ Relationship to you __________________________________

Is this beneficiary married? Yes ____________ No _____________

If yes, do you wish to designate the spouse as the alternate beneficiary if this beneficiary is deceased? Yes_____________ No _____________

Does this beneficiary have any children? Yes _________ No __________

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


BENEFICIARY 4:

Name ______________________________________________

Date of birth ______________________________________________ Relationship to you __________________________________

Is this beneficiary married? Yes ____________ No _____________

If yes, do you wish to designate the spouse as the alternate beneficiary if this beneficiary is deceased? Yes_____________ No _____________

Does this beneficiary have any children? Yes __________ No ___________

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


PLEASE ADD ANOTHER SHEET FOR ADDITIONAL BENEFICIARIES


FINANCIAL INFORMATION


1. REAL ESTATE:

RESIDENCE                                                                                     Value $____________

Less mortgage with _________________________              ($____________)

                                                                                                   Net Equity $____________

2. OTHER REAL ESTATE                                                                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) ________________________________________ $____________ ________________________________________ $____________ ________________________________________ $____________

                                                                 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 ____________________________ $____________

_____ shs. of ____________________________ $____________

_____ shs. of ____________________________ $____________

                                                                                Total Stocks $____________


5. BONDS (list total values only)

U. S. Gov't E and EE Savings Bonds (face value)                $____________

U. S. Gov't H Bonds, T-Bonds, and Notes                            $____________

Municipal Bonds                                                                         $____________

Corporate or Other Bonds                                                       $____________

                                                                                 Total Bonds $____________


6. BANK ACCOUNTS (list name of financial institution and average balance) Checking ______________________________       $____________

Checking ______________________________        $____________

Money Market ____________________________  $____________

Savings ______________________________           $____________

Certificate of Deposit ________________________ $____________ Certificate of Deposit ________________________ $____________

Other ______________________________               $____________

                                                                    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.) ____________________________________________ $___________ ____________________________________________ $___________                                                                                                      Total Notes $___________


8. BUSINESS INTERESTS

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

Name of Business ____________________________             $_________

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. 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 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 your life insurance (death value)                      $__________

                                                                     Total Estate Value           $__________


Thank you for completing this estate planning questionnaire.