Date of First Appointment__________________________

Date of Second Appointment________________________

Date of Third Appointment_________________________
Date of Fourth Appointment________________________

ESTATE ANALYSIS CHECKLIST

Estate planning is the process through which you provide for yourself and your family during retirement,
upon disability, and after death. An estate plan puts your legal and financial affairs in order so that whatever you
own will be preserved and distributed to your heirs with the least amount of financial and emotional cost.
This Checklist is intended to assist you in gathering the information necessary for the analysis, design, and
implementation of your estate plan. Your completing this Checklist as fully as possible will improve your estate
plan and lessen your legal fees. The Checklist has seven parts:
1.

Introduction. We need to know how you want us to help you.

2.

Legal and Financial Documents. We have asked for these documents because discussing your
estate planning options may involve analyzing these documents.

3.

Personal and Family Information. We use this information in your documents, so we need
complete names and addresses.

4.

Assets and Liabilities. We can properly prepare your estate plan only if you fully disclose your
assets and liabilities to us. We will not work with you if you will not provide this information.

5.

Fiduciaries. A fiduciary is a person or institution having a duty to act for the best interests of
another person. You need to thoughtfully decide upon the people who you trust for these
responsibilities.

6.

Distribution of Estate. Instead of completing this section, we can use a financial statement or
analysis prepared by you or your financial advisor if the statement fully discloses your assets and
liabilities. This is the most important part of your estate plan and therefore the section that we will
probably spend the most time discussing.

7.

Miscellaneous Issues. The answers to these questions will affect our recommendations to you.

Please complete as much of this checklist as you can BEFORE your appointment.
Page 1 of 21

SECTION 1. Introduction
1.

Did you read the Estate Planning Options Article that was included in your information packet?
Client 1:

2.

Client 2:

Yes_____ No______

What are your estate planning goals? Indicate order of importance by number in descending order with
10 being the most important and 1 being the least important.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

3.

Yes_____ No_____

Providing for spouse or partner.

Providing for children.
Providing for persons other than spouse, partner, or children.
Providing for childrens or grandchildrens education.
Preserving/protecting estate property.
Minimizing estate taxes.
Avoiding probate.
Providing estate liquidity.
Making charitable contributions.
Providing specifically for an ill or disabled child, dependent, or person.

_____
_____
_____
_____
_____
_____
_____
_____
_____
_____

Please describe any other legal goals:_______________________________________________________

___________________________________________________________________________________

4.

Do you have any disabilities or illnesses?

Client 1:
Yes____ No____
Client 2:
Yes____ No____
If yes, please describe__________________________________________________________________
___________________________________________________________________________________

5.

Who referred you to this office?___________________________________________________________

6.

Have you consulted with any other lawyers about your estate plan? If yes, who?____________________
____________________________________________________________________________________

7.

Do you know if any of your relatives are clients of our office? If yes, who?_________________________
___________________________________________________________________________________
SECTION 2. LEGAL AND FINANCIAL DOCUMENTS
Please bring the following documents to our first meeting:
____ Wills
____ Trusts
____ Deeds
____ Leases
____ Mortgages
____ Living Wills
____ Promissory Notes
____ Buy-Sell Agreements
____ Pre-Need Funeral Contract
____ Birth Certificates (Clients & Children)

____ Life Insurance Policies

____ Premarital Agreements
____ Decrees of Divorce/Dissolution
____ Powers of Attorney
____ Titles to Motor Vehicles
____ Employees Benefits Statements
____ Stock Redemptions
____ Funeral and Burial Instructions
____ Durable Powers of Attorney for Health Care
____ Military Discharges (DD-214)

Page 2 of 21

SECTION 3. PERSONAL AND FAMILY INFORMATION

Personal Information
Client 1

Client 2

Full Name:

_________________________

_________________________

Preferred form of address:

Dr.

Dr.

Other or Previous Names:

_________________________

Mr.

Mrs.

Ms.

Miss

Mr.

Mrs.

Ms.

Miss

_________________________

Include nicknames.

Home Address (Street):

_______________________________________________________

(City, State, Zip):

_______________________________________________________

County and Municipality:

_______________________________________________________

Home Telephone:

(_____)_________________________________________________

Cell Phone:
(_____)___________________
May we communicate with you via cell phone? Yes No

(_____)___________________
Yes No

Email Address:

_________________________

_________________________

Do you currently receive our email newsletter?

Occupation:

Yes

No

_________________________

Do you or your spouse receive benefits from General Motors?

Employer/Retired from:
Circle one.
Work Address:

May we communicate with you via email?

Yes

No

Yes No

_________________________
If retired, what did you do?

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

Work Telephone:

(_____)___________________

(_____)___________________

Birth Date:

_________________________

_________________________

Birthplace:

_________________________

_________________________

Social Security Number:

_________________________

_________________________

Date/Place of Marriage:

__________________________________Premarital Agreement? Yes No

U.S. Citizen?

_________________________

_________________________

Auto Tags Where (State)?

_________________________

_________________________

Income Tax Paid Where (State)?_________________________

_________________________

Vote Where (State)?

_________________________

_________________________

Page 3 of 21

Client 1

Client 2

Armed Forces Service

Branch
Serial Number
Did you serve during a war?
Do you receive benefits?
If yes, what kind?

____________________
____________________
____________________
____________________
Yes_____ No_____ Which one?
Yes_____ No_____ Which one?
Yes_____ No _____
Yes_____ No_____
____________________________________________

Have you ever been married?

Yes_____

No_____

Please list all prior marriages below.

Former spouses name:
____________________

Yes_____ No_____
____________________

Date/place of marriage:

____________________

____________________

Date terminated:

____________________

____________________

How terminated?

Death____ Divorce____
Death____ Divorce____
Dissolution _____
Dissolution _____
If death, was a Federal estate tax return filed?
Yes No (Circle one.) If yes, provide us with a copy.
Divorce/dissolution obligations to children or to or from former spouse:
Child support:

____________________

____________________

Alimony:

____________________

____________________

Life insurance:

____________________

____________________

Other:

____________________

____________________

PARENTS (If deceased, write full names and dates of death.)

Fathers Name

____________________

____________________

Address

____________________

____________________

Telephone

____________________

____________________

Birth Date

____________________

____________________

Financially Dependent?

____________________

____________________

Mothers Name

____________________

____________________

Address

____________________

____________________

Telephone

____________________

____________________

Birth Date

____________________

____________________

Financially Dependent?

____________________

____________________

Page 4 of 21

CHILDREN (Include all deceased children and their dates of death. Attach additional page if necessary.)
Is there a physical possibility of more children?______________________________________________________
Are any children adopted?_____________________________________________________________________
Are any children disabled or in poor health?________________________________________________________
If your children are married, what is the quality of your relationship with them and their spouses?_____________
_________________________________________________________________________________________
1.
Childs Full Name_____________________________________Child of ____Client 1 ____Client 2
Home and Email addresses___________________________________________________________________
Home Phone____________________________ Social Security Number_______________________________
Occupation______________________________________________Birth Date___________________________
Childs Spouses Name____________________________________Occupation__________________________
Childs Children__________________________________________Birth Date___________________________
_______________________________________________________Birth Date___________________________
Special information about child or childs family that Lawyer should know:_______________________________
_________________________________________________________________________________________
2.
Childs Full Name_____________________________________Child of ____Client 1 ____Client 2
Home and Email addresses___________________________________________________________________
Home Phone____________________________ Social Security Number________________________________
Occupation_____________________________________________Birth Date___________________________
Childs Spouses Name___________________________________Occupation__________________________
Childs Children__________________________________________Birth Date____________________________
______________________________________________________ Birth Date____________________________
Special information about child or childs family Lawyer should know:___________________________________
_________________________________________________________________________________________
3.
Childs Full Name_____________________________________Child of ____Client 1 ____Client 2
Home and Email addresses___________________________________________________________________
Home Phone____________________________ Social Security Number_________________________________
Occupation_____________________________________________Birth Date_____________________________
Childs Spouses Name__________________________________Occupation___________________________
Childs Children_________________________________________ Birth Date_____________________________
_____________________________________________________Birth Date____________________________
Special information about child or childs family Lawyer should know:___________________________________
_________________________________________________________________________________________
4.
Childs Full Name_____________________________________Child of ____Client 1 ____Client 2
Home and Email addresses___________________________________________________________________
Home Phone____________________________ Social Security Number_________________________________
Occupation____________________________________________Birth Date_____________________________
Childs Spouses Name_________________________________ Occupation___________________________
Childs Children________________________________________Birth Date______________________________
____________________________________________________Birth Date_____________________________
Special information about child or childs family that Lawyer should know:_______________________________
_________________________________________________________________________________________

Page 5 of 21

BROTHERS AND SISTERS OF CLIENT 1 (Include deceased and dates of death.)

Name______________________________________________________ Living?___________
Birth Date__________ Home Phone________________ Children?_______ How many?_______
Address_____________________________________________________________________
Name______________________________________________________ Living?___________
Birth Date__________ Home Phone________________ Children?_______ How many?_______
Address_____________________________________________________________________
Name______________________________________________________ Living?___________
Birth Date__________ Home Phone________________ Children?_______ How many?_______
Address_____________________________________________________________________
Name______________________________________________________ Living?___________
Birth Date__________ Home Phone________________ Children?_______ How many?_______
Address_____________________________________________________________________
Name______________________________________________________ Living?___________
Birth Date__________ Home Phone________________ Children?_______ How many?_______
Address_____________________________________________________________________

BROTHERS AND SISTERS OF CLIENT 2 (Include deceased and dates of death.)

Name______________________________________________________ Living?___________
Birth Date__________ Home Phone________________ Children?_______ How many?_______
Address_____________________________________________________________________
Name______________________________________________________ Living?___________
Birth Date__________ Home Phone________________ Children?_______ How many?_______
Address_____________________________________________________________________
Name______________________________________________________ Living?___________
Birth Date__________ Home Phone________________ Children?_______ How many?_______
Address_____________________________________________________________________
Name______________________________________________________ Living?___________
Birth Date__________ Home Phone________________ Children?_______ How many?_______
Address_____________________________________________________________________
Name______________________________________________________ Living?___________
Birth Date__________ Home Phone________________ Children?_______ How many?_______
Address_____________________________________________________________________

Page 6 of 21

Personal Advisors
Client 1

Client 2

Accountant:
Name:________________________________
Firm:_________________________________
Address:______________________________
_____________________________________
Telephone:_____________________________

Accountant:
Name:________________________________
Firm:_________________________________
Address:______________________________
_____________________________________
Telephone:_____________________________

Doctor:
Name:________________________________
Firm:_________________________________
Address:______________________________
_____________________________________
Telephone:_____________________________

Doctor:
Name:________________________________
Firm:_________________________________
Address:______________________________
_____________________________________
Telephone:_____________________________

Financial Advisor:
Name:________________________________
Firm:_________________________________
Address:______________________________
_____________________________________
Telephone:_____________________________

Financial Advisor:
Name:________________________________
Firm:_________________________________
Address:______________________________
_____________________________________
Telephone:_____________________________

Life Insurance Agent:

Name:________________________________
Firm:_________________________________
Address:______________________________
_____________________________________
Telephone:_____________________________

Life Insurance Agent:

Name:________________________________
Firm:_________________________________
Address:______________________________
_____________________________________
Telephone:_____________________________

Trust Officer:
Name:________________________________
Firm:_________________________________
Address:______________________________
_____________________________________
Telephone:_____________________________

Trust Officer:
Name:________________________________
Firm:_________________________________
Address:______________________________
_____________________________________
Telephone:_____________________________

Pastor, Priest, Rabbi, Clergy:

Name:________________________________
Place of Worship: _______________________
Address:______________________________
_____________________________________
Telephone:_____________________________

Pastor, Priest, Rabbi, Clergy:

Name:________________________________
Place of Worship: _______________________
Address:______________________________
_____________________________________
Telephone:_____________________________

Page 7 of 21

SECTION 4. ASSETS & LIABILITIES

ASSETS
Residence:

Client 1

Client 2

Joint Names

______________
______________

_______________
_______________

Other Real Estate:

Ohio
Non-Ohio
Cash & Equivalents:
Checking Account(s)
Savings Account(s)
CDs & Money Market
Marketable Securities:
Stock/Options
Taxable Bonds
Tax-Exempt Bonds
Mutual Funds
Life Insurance
Face/Cash values
Business Interests:
Retirement Plans:
Pension/Profit Sharing
IRAs (Traditional)
IRAs (Roth)
Annuities (after-tax) ______________
Annuities (pre-tax) ______________
Personal Property:
Collections of value
Other
Other Assets
(Patents, Copyrights, Powers of Appointment, etc.)
TOTAL ASSETS
INCOME (monthly):
Salary/Wages
Social Security
Pension-related
Investments
Alimony/Rental
Other (please specify)
TOTAL INCOME

Page 8 of 21

LIABILITIES
Residence:
First Mortgage

Client 1

Client 2

Joint Names

TOTAL LIABILITIES:

NET WORTH:
(Assets minus Liabilities)

Second Mortgage
Other Mortgages:
Personal Loans:
Income Taxes:
Other Debts:

Please identify any assets that were acquired in a community property state (Alaska, Arizona, California,
Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, Wisconsin).

REAL ESTATE OWNED (Attach an additional sheet if necessary)

1. Address______________________________________________________________________________
County and Municipality____________________________________________________________________
Legal Title in Whose Name__________________________________________________________________
Date Acquired____________________________________________________________________________
Mortgage: Amount______________________________________ Mortgagee__________________________
Fair Market Value______________________________________ Purchase Price_______________________
How Property Acquired (examples: purchase, gift)_________________________________________________
2. Address______________________________________________________________________________
County and Municipality____________________________________________________________________
Legal Title in Whose Name__________________________________________________________________
Date Acquired____________________________________________________________________________
Mortgage: Amount______________________________________ Mortgagee__________________________
Fair Market Value______________________________________ Purchase Price_______________________
How Property Acquired (examples: purchase, gift)_________________________________________________
3. Address______________________________________________________________________________
County and Municipality____________________________________________________________________
Legal Title in Whose Name__________________________________________________________________
Date Acquired____________________________________________________________________________
Mortgage: Amount______________________________________ Mortgagee__________________________
Fair Market Value______________________________________ Purchase Price_______________________
How Property Acquired (examples: purchase, gift)_________________________________________________
Page 9 of 21

BANK, SAVINGS, AND CREDIT UNION ACCOUNTS

1.

Name of Institution___________________________________________________________
Average Balance_____________________ Type of Account__________________________
In Whose Name?____________________________________________________________

2.

Name of Institution___________________________________________________________
Average Balance_____________________ Type of Account__________________________
In Whose Name?____________________________________________________________

3.

Name of Institution___________________________________________________________
Average Balance_____________________ Type of Account__________________________
In Whose Name?____________________________________________________________

4.

Name of Institution___________________________________________________________
Average Balance_____________________ Type of Account__________________________
In Whose Name?____________________________________________________________

5.

Name of Institution___________________________________________________________
Average Balance_____________________ Type of Account__________________________
In Whose Name?____________________________________________________________

ASSET/DOCUMENT SAFEKEEPING

1.

Where do you keep your valuable papers?_________________________________________

2.

Can your spouse/partner, executor, trustee, or power of attorney locate your assets and legal
documents?
Client 1____________
Client 2___________

3.

Have you discussed your estate plan with the people who will be affected by it?
Client 1____________
Client 2___________

4.

Location of Safe Deposit Box_______________________ Location of Keys_____________

Any Property of Others in Box?____________________ Identifiable as Such?___________
Safe Deposit Box Number________________________
Names on Safe Deposit Box_________________________________________________

Page 10 of 21

ANNUITIES, IRAs, PENSIONS, AND RETIREMENT PLANS

Please explain monthly income and death benefits.

Type of Plan
_______________
_______________
_______________
_______________
_______________

Annuity (A)
or Lump Sum
Payout (LS)
____________
____________
____________
____________
____________

Beneficiaries
____________________________
____________________________
____________________________
____________________________
____________________________

Total Value
_______________
_______________
_______________
_______________
_______________

INVESTMENTS: Stocks, Bonds, Contracts, Notes, Mortgages, Trust Deeds, Other

Name of Company,
Municipality, or
Investment
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________
_______________

How Acquired:
Gift, Inheritance
or Purchase?
Date
(G) (I) (P)
Acquired
___________ ________
___________ ________
___________ ________
___________ ________
___________ ________
___________ ________
___________ ________
___________ ________
___________ ________
___________ ________
___________ ________
___________ ________

Purchase
Price
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______

How
Owned?
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______

Percent
Contributed
by each
Joint Tenant
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________

Value
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________
_________

OTHER ASSETS (Attach separate page if necessary)

Motor Vehicles (make, model, fair market value, how titled)_________________________________
___________________________________________________________________________________
__________________________________________________________________________________
Boats, Trailers, Campers, etc.___________________________________________________________
___________________________________________________________________________________
Mortgages, Land Contracts, or Other Receivables____________________________________________
__________________________________________________________________________________
___________________________________________________________________________________
Coin Collections, Family Heirlooms, Antiques_____________________________________________
__________________________________________________________________________________
Other Assets (animals, copyrights, patents, stock options, powers of appointment)________________
___________________________________________________________________________________
___________________________________________________________________________________

Page 11 of 21

LIFE INSURANCE INFORMATION

Client 1
Company

Policy Type Face Value

Cash Value

______________

__________

__________

__________

________________

_______________

______________

__________

__________

__________

________________

_______________

______________

__________

__________

__________

________________

_______________

______________

__________

__________

__________

________________

_______________

______________

__________

__________

__________

________________

_______________

__________

__________

TOTAL:

Insured

Owner

Beneficiary
Primary:________________
Secondary:______________
Primary:________________
Secondary:______________
Primary:________________
Secondary:______________
Primary:________________
Secondary:______________
Primary:________________
Secondary:______________

Client 2
Company

Policy Type Face Value

Cash Value

______________

__________

__________

__________

________________

_______________

______________

__________

__________

__________

________________

_______________

______________

__________

__________

__________

________________

_______________

______________

__________

__________

__________

________________

_______________

______________

__________

__________

__________

________________

_______________

__________

__________

TOTAL:

Insured

Page 12 of 21

Owner

Beneficiary
Primary:________________
Secondary:______________
Primary:________________
Secondary:______________
Primary:________________
Secondary:______________
Primary:________________
Secondary:______________
Primary:________________
Secondary:______________

BUSINESS INTERESTS
Client 1 Business Interests
Name of
Business:__________________________________________________________________________________

Address:___________________________________

Telephone Number:__________________________

____________________________________

Email Address:______________________________

Nature of
Business:__________________________________________________________________________________
Do you have a Buy-Sell Agreement?
If Yes, please provide a copy.

__________ Yes

__________ No

Kind of Entity:
(Check one)
Sole Proprietorship: _________________ Partnership:
___________________
C Corporation:
_________________ S Corporation*: ___________________
Limited Liability Company: ____________ Family Limited Partnership:___________
Other (explain):
____________________________________________________
*We must know if the business is an S Corporation because only special
types of trusts can be shareholders of S Corporation stock.

Percentage of interest owned by Client 1: ______________

By Client 2: _______________

Children involved in business:

Percentage Owned:

_____________________________________________

___________________

_____________________________________________

___________________

_____________________________________________

___________________

Tax basis: ______________________________

Book value:______________________

Your estimate of present value of entire business: __________________________________________

(Include on Business Interests line in Section 4)

Page 13 of 21

Client 2 Business Interests

Name of
Business:__________________________________________________________________________________

Address:___________________________________

Telephone Number:__________________________

____________________________________

Email Address:______________________________

Nature of
Business:__________________________________________________________________________________
Do you have a Buy-Sell Agreement?
If Yes, please provide a copy.

__________ Yes

__________ No

Kind of Entity:
(Check one)
Sole Proprietorship: _________________ Partnership:
___________________
C Corporation:
_________________ S Corporation*: ___________________
Limited Liability Company: ____________ Family Limited Partnership:___________
Other (explain):
____________________________________________________
*We must know if the business is an S Corporation because only special
types of trusts can be shareholders of S Corporation stock.

Percentage of interest owned by Client 1: ______________

By Client 2: _______________

Children involved in business:

Percentage Owned:

_____________________________________________

___________________

_____________________________________________

___________________

_____________________________________________

___________________

Tax basis: ______________________________

Book value:______________________

Your estimate of present value of entire business: __________________________________________

(Include on Business Interests line in Section 4)

Page 14 of 21

SECTION 5. FIDUCIARIES
Executor
The executor of your estate is the person or institution who will have the responsibilities of carrying
out the terms of your will and supervising the administration of your estate. The executor is entitled to statutory
compensation for serving. Alternates should be named if your first choice is unable or unwilling to serve. You
can choose two or more people to serve together as executor.

First Choice:_________________________________________________________
Second Choice:______________________________________________________
Third Choice:________________________________________________________
If naming coexecutors, will they serve independently or unanimously?

Guardian/Custodian
If you have minor or incompetent children, a guardian for them should be appointed in your will.
Name the person who should have physical custody of your children until they are of legal age (18 in Ohio) if
both you and your childs other parent die before then. If you judge that a person other than the guardian would
better manage the finances belonging to the children, a separate custodian, trustee, or guardian of estate should
be named who would be responsible for managing your childrens assets until they reach legal or some other
age that you choose. Alternates should be named if your first choice is unable or unwilling to serve. Note: The
court will appoint only one guardian per child, even though you want your children to live in a two-parent
household.

First Choice:_________________________________________________________
Second Choice:______________________________________________________
Third Choice:________________________________________________________
Trustee/Trust Advisor
If a trust is used in your estate plan, you should name (a) a trustee to administer the trust and (b) a trust
advisor to whom the trustee will be accountable.
The trustee is the person or institution that holds the title to the trust property and manages and
administers the trust. The trustee should be financially responsible and familiar with the needs of your
beneficiaries. The trustee is entitled to compensation for serving. Alternates should be named if your first
choice is unable or unwilling to serve. You can choose two or more people to serve together as trustee.
The trustee advisor is the person to whom the trustee will be accountable for the trustees activities.
Therefore, you should name different people for the trust advisor than you name for the trustee.

First Choice:_________________________________________________________
Second Choice:______________________________________________________
Third Choice:________________________________________________________
If naming cotrustees, will they serve independently or unanimously?

Attorney in Fact/Agent
Your attorney in fact or agent is a person who you have authorized to act on your behalf either for a
specific purpose or in a general capacity. The authority is conferred in a written document, typically a power
of attorney. You can choose two or more people to serve together. Your agent can act for you when you sign
your power of attorney or only when your doctor determines that you cannot act for yourself.

First Choice:_________________________________________________________
Second Choice:______________________________________________________
Third Choice:________________________________________________________
If naming coagents, will they serve independently or unanimously? Effective immediately or upon incapacity?

Page 15 of 21

SECTION 6. DISTRIBUTION OF YOUR ESTATE

Because the exact amount of your estate cannot be determined when your will or trust
is prepared, distributing your estate on a percentage basis is generally advisable, except if you
are survived by a spouse or partner, who you may want to receive all of your estate. You
may wish, however, to designate certain personal effects, real estate, or even cash to
individuals or organizations before the remainder of your estate is divided percentage-wise.
There are alternatives to making specific gifts in your will or trust, such as preparing a
supplemental list of your specific gifts, which you can keep with your will or trust document
and easily update from time to time, or marking specific items of property with the name of
their intended beneficiary. These alternatives do not, however, have the legal certainty of
specific designations in your will or trust.
Please advise us if any of the beneficiaries are NOT citizens of the United States.
1.

Upon death of Client 1__________________________________________________

________________________________________________________________________
2.

Upon death of Client 2__________________________________________________

________________________________________________________________________
3.

Upon deaths of both Client 1 and Client 2 (If to children: At what ages? Per stirpes

or per capita? ____________________________________________________________

________________________________________________________________________
4.

Upon death of Client 1, Client 2, and all children___________________________

_________________________________________________________________________
5.
Special distributions to specific persons or organizations (Name and address of
beneficiary; item or amount of money or percentage of estate)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
6.
If you have minor children when you die, do you want to give an amount of money
to the person who you appoint as the guardian of your children to assist the guardian with
remodeling the guardians present home or purchasing a new home or car in order to
accommodate your children?
Client 1:

Yes____

No____

Page 16 of 21

Client 2:

Yes____

No____

7.

In considering the disposition of your property during your lifetime or after your death,
have you considered the needs of your heirs or distributees or the size of their estates,
now or in the future? If so, what considerations were used for each person? ________
_____________________________________________________________________

8.

If you have any animals, what do you want done with them after your death? __________
_____________________________________________________________________

9.

Do you have any relatives/persons whom you have or anticipate having a desire or
obligation to support?
_____________________________________________________________________

10.

How do you plan to face the financial obligations of disability? (For example, you have
to live in a nursing home because you have dementia or had a stroke or you were injured
or ill and cant work.) _____________________________________________________
_____________________________________________________________________

11.

Have you stored or do you plan to store any genetic material (sperm, eggs, frozen
embryos, for example) to enable conception of a human being?
Client 1:

Yes____

No____

Client 2:

Yes____

No____

If genetic material results in the birth of a child after your death, do you want the child
to inherit from you as your other heirs would?
Client 1:

Yes____

No____

Client 2:

Yes____

No____

IF YOU ARE NOT MARRIED, ANSWER QUESTIONS 11 THROUGH 13.

IF YOU ARE MARRIED, ANSWER QUESTIONS 13 THROUGH 20.
12.

What monthly amount would be required to care for your children after your death?
(Do not consider inflation.)
$_______________________

13.

Upon your death, what assets could be sold to pay taxes, expenses, and debts? ______
_____________________________________________________________________

14.

Describe any assets that you do not want sold after your death.
Client 1:______________________________________________________________
Client 2:______________________________________________________________

Page 17 of 21

15.

Do you think that your spouse is capable of managing large sums of money after your
death?
Client 1:

Yes____

No____

Client 2:

Yes____

No____

Would you prefer a professional trustee to assist your spouse in managing money after
your death?
Client 1:
16.

Yes____

No____

Client 2:

Yes____

No____

Would you wish to or be able to work supporting your family if your spouse dies?
Client 1:

Yes____

No____

Client 2:

Yes____

No____

If so, what would the expected monthly earnings be?

Client 1:
Client 2:

$
$

17.

What is the minimum monthly income you would need if your spouse dies? (Do not
consider inflation.)
Client 1: $
Client 2: $

18.

What additional monthly amounts would you need to care for your children? (Do not
consider inflation.)
Client 1: $
Client 2: $

19.

Would you expect or prefer your spouse to keep your present home if you die?
Client 1:

20.

Yes____

No____

Client 2:

Yes____

No____

On the death of the first spouse, what assets could be sold to pay taxes, expenses, and
debts?
_________________________________________________________________
_________________________________________________________________

21.

Would remarriage of either spouse affect property distribution?

Client 1:

Yes____

No____

Client 2:

Page 18 of 21

Yes____

No____

SECTION 7. MISCELLANEOUS ISSUES

PLEASE ANSWER THESE QUESTIONS EITHER YES OR NO.

Expected Gifts and Inheritances
Are you expecting any gifts or inheritances?
Client 1:

Yes____

No____

Client 2:

Yes____

No____

Details (amount, source, date, etc.): ___________________________________________

________________________________________________________________________
Previous Gifts
Please list outright gifts made in excess of $10,000 per year to a person excluding gifts made by
Client 1 or Client 2 to each other if Client 1 and Client 2 are married to each other: (Attach
separate sheet if necessary.)
Client 1

Client 2

Donee:_______________________
Date: ________________________
Amount:______________________

Donee:_____________________
Date: ______________________
Amount:____________________

Donee:_______________________
Date: ________________________
Amount:______________________

Donee:_____________________
Date: ______________________
Amount:____________________

Gifts of any amount made in trust:___________________________________________

Have you filed any gift tax returns (IRS Form 709 or otherwise)?________ If yes, please provide copies.
Trust Benefits and Responsibilities
1.

2.

Are you beneficiary of any trusts?

Client 1:
Yes____ No____

Client 2:

Yes____

No____

Do you possess any powers of appointment?

Client 1:
Yes____ No____
Client 2:

Yes____

No____

3.

Are you a trustee or do you have any other power with respect to any trust?
Client 1:
Yes____ No____
Client 2:
Yes____
No____

4.

Have you established any trusts?

Client 1:
Yes____ No____

Client 2:

Page 19 of 21

Yes____

No____

Qualified Plan Benefits

1.

2.

If either Client 1 or Client 2 has separated from employment service before January 1,
1983, and has not changed the form of benefit of a qualified plan, please describe the
details of the plan, the beneficiary, and form of benefit designation in effect after
December 31, 1982.
__________________________________________________________________
__________________________________________________________________
Did you make a so-called grandfather election in connection with your retirement plan,
IRA, or similar type of plan? Client 1:__________ Client 2:____________
Community Property (Client 1 or Client 2)

1.

Since your marriage, have you and your spouse always lived in your present state of
residence?________________________________
If not, in what states did you formerly reside?_______________________________

2.

If you or your spouse, while married to each other, has lived in a state that has
community property law (Alaska, Arizona, California, Idaho, Louisiana, Nevada, New
Mexico, Texas, Washington, Wisconsin), give details and status of assets brought into
this state from the state.
_____________________________________________________________________
Joint Property Interests

If Client 1 and Client 2 own any joint property interests that were acquired or created before
January 1, 1977, please list the joint property interests and provide the date on which they were
acquired or created.
Details:_____________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Loans and Mortgages
Have you guaranteed any loans or pledged any assets as security on behalf of any family
members, other persons, or business entity?
Client 1:
Yes____ No____
Client 2:
Yes____
No____
Details:______________________________________________________________
Does anyone owe you any money?
Client 1:
Yes____ No____
Client 2:
Yes____
No____
Details:______________________________________________________________

Page 20 of 21

Funeral and Burial Arrangements

Do the people who will feel responsible for your funeral and burial know your preferences about
these matters?
Client 1:
Yes____ No____
Client 2:
Yes____
No____
Details:_____________________________________________________________________
___________________________________________________________________________
Insurance Matters
1.
2.

Are you insurable?

Client 1:
Yes____

No____

Do you have disability income insurance?

Client 1:
Yes____ No____

Client 2:

Yes____

No____

Client 2:

Yes____

No____

3.

Do you have long-term care (nursing home) insurance? See www.longtermcare.gov

Client 1:
Yes____ No____
Client 2:
Yes____
No____
If yes, please bring your policies to our appointment.

4.

Do you have umbrella liability insurance?

Client 1:
Yes____ No____

5.

Client 2:

Yes____

No____

Do you have identity theft insurance or have you frozen your credit?
Client 1:
Yes____ No____
Client 2:
Yes____
If yes, please indicate which.

No____

Other Issues
1.
2.

Do you have a passport?

Client 1:
Yes____

No____

Client 2:

Do you plan or desire to move from the State of Ohio?

Client 1:
Yes____ No____
Client 2:

Yes____

No____

Yes____

No____

3.

If you have served in the military, are your discharge papers recorded?
Client 1:
Yes____ No____
Client 2:
Yes____
No____

4.

Have you ever been hospitalized or in a nursing home for 30 continuous days?
Client 1:
Yes____ No____
Client 2:
Yes____
No____
If yes, please provide admission and discharge dates and explain the reason for care.

Details:_____________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

January 2015
Page 21 of 21