CONFIDENTIAL ESTATE PLANNING QUESTIONNAIREPlease read the following instructions carefully. The questionnaire below is designed to expedite our efforts to plan your estate. Whether you are a new or an established client, we have found this questionnaire extremely helpful, and therefore ask you to complete it prior to your appointment. Those questions that do not apply to your family or financial situation may simply be left blank. Please feel free to attach additional pages where space is needed or to provide other information you feel is relevant. There is a space below to upload any of your documents securely. Our site uses SSL Encryption to protect your data. NOTE: DO NOT RELOAD OR REFRESH THIS PAGE AS YOU COMPLETE THE FORM, AS THAT MAY CAUSE YOUR INFORMATION TO BE DELETED. IF YOU NEED TO COME BACK TO COMPLETE THE QUESTIONNAIRE, YOU CAN HIT “SAVE AND CONTINUE” AT THE BOTTOM OF THIS PAGE. YOU WILL RECEIVE AN EMAIL WITH A LINK TO CONTINUE/COMPLETE THE QUESTIONNAIRE. Today's Date:(Required) MM slash DD slash YYYY Name(Required) First Middle Last Address(Required) Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth MM slash DD slash YYYY Phone(Required)Phone (Other)Email(Required) EmployerSpouse / Partner Name First Middle Last Date of Marriage or Domestic Partnership MM slash DD slash YYYY State of Marriage or Domestic PartnershipBeneficiariesBeneficiaries can be a spouse/partner, child, grandchild or non-relative. Please use the + button to the right to add additional beneficiaries.BeneficiariesNameRelationAddresss Add RemovePlease use the + button to the right to add additional beneficiaries. Business InterestsPlease provide detail regarding any business interests you holdName of BusinessValue (Estimated) of BusinessBusiness AddressAre you interested in Succession Planning Yes No Unsure Professional AdvisorsPlease provide contact information for attorneys, financial advisors, brokers, insurance agents, etc.AdvisorNameTitleEmail AddressPhone Number Add RemovePlease use the + button to the right to add additional advisors. AssetsPlease provide information regarding any personal assets. If you have statements, deeds, property tax bills, etc., please attach them below, or bring them to your appointment. Please List Any Monthly Family Income (ie: Wages, Social Security, Retirement, Other)Income SourceAmount Add RemovePlease use the + button to the right to add additional income. Bank AccountsName of Financial InstitutionAccount ValuePurpose of Account Add RemovePlease use the + button to the right to add additional accounts. Do You Own Real Property? Yes No If Yes, Who Holds the Mortgage?What is the Estimated Market Value?What is the Amount MortgagedWhen Does the Mortgage Mature?Additional Property Mortgage HolderAdditional Property Estimated Market Value?Additional Property Amount MortgagedAdditional Property Mortgage Maturity DatePlease List Any Valuable Personal Property (ie: Vehicles, Jewelery, Home Furnishings, Artwork) Add RemovePlease use the + button to the right to add additional personal property. Personal RepresentativesThese are people you trust to represent you and carry out your wishes, financial and otherwise.Who Do You Trust to Make Financial Decisions?NameAddress Add RemovePlease use the + button to the right to add additional people. Who Do You Trust to Make Healthcare Decisions?NameAddress Add RemovePlease use the + button to the right to add additional people. Who Do You Trust to Take Care of Your Children?NameAddress Add RemovePlease use the + button to the right to add additional people. Who Do You Trust to Take Care of Your Pets?NameAddress Add RemovePlease use the + button to the right to add additional people. Specific BequestsAre there any specific requests you want to discuss in your appointment (ie: charitable gifts, items or money to go to specific people?)If yes, please describe them here:Please Provide Specific Funeral Instructions, If Any (ie: Cremation, Memorial Service, Services)Who would you like to handle your remains and final arrangements?AddressThank YouThank you for taking the time to complete this questionnaire; it is very helpful for your appointment. If you have any questions regarding this questionnaire or your appointment, please contact James Gonda at 518-459-2100.Upload Files Securely Here (ie: bank statements, tax documents, deeds, etc.)Please provide any relevant documents you would like to share with our attorneys. Drop files here or Select files Max. file size: 20 MB.
