Estate, Health Care & Medicaid Planning
Questionnaire - Married

Estate, Health Care, and Medicaid Planning Questionnaire - Married
 

INSTRUCTIONS:

  • Please complete the questionnaire completely to the best of your ability. You may call our office for assistance.
  • Your accuracy and completeness in responding will help us to best advise and represent you. Please complete ALL parts of the questionnaire or we will be unable to meet with you.

I. GENERAL INFORMATION
Were you referred to our office and if so, by whom?
If not, what made you choose our office?
What is the purpose of your visit to our office?
Do you have any other legal issues which our office should be aware of? If yes, please explain.
 
II. BACKGROUND AND FAMILY INFORMATION
1.

Husband:
Name:
D.O.B.: SS#:
Phone Number(s): (H) (C) (O)
Email:
Current Address:
If deceased, date, country, and state of death:

Wife:
Name:
D.O.B.: SS#:
Phone Number(s): (H) (C) (O)
Email:
Current Address:
If deceased, date, country, and state of death:

2. Date of Marriage:
Is this the 1st, 2nd, 3rd, or 4th Marriage:

3.

Children (please indicate whether any child is from a prior marriage.) For minors, include their age:
Include Deceased Children

  HUSBAND WIFE
Name\Age
Relationship
Address
Phone #
Adoped/Half-blood
  HUSBAND WIFE
Name\Age
Relationship
Address
Phone #
Adoped/Half-blood
  HUSBAND WIFE
Name\Age
Relationship
Address
Phone #
Adoped/Half-blood
  HUSBAND WIFE
Name\Age
Relationship
Address
Phone #
Adoped/Half-blood

 


 

4. Grandchildren:
  HUSBAND WIFE
Name\Age
Relationship
Address
Phone #
Adoped/Half-blood
  HUSBAND WIFE
Name\Age
Relationship
Address
Phone #
Adoped/Half-blood
  HUSBAND WIFE
Name\Age
Relationship
Address
Phone #
Adoped/Half-blood
  HUSBAND WIFE
Name\Age
Relationship
Address
Phone #
Adoped/Half-blood

 

 


5.

If no surviving children, list names of living siblings for each spouse

  HUSBAND WIFE
Name\Age
Relationship
Address
Phone #
  HUSBAND WIFE
Name\Age
Relationship
Address
Phone #
  HUSBAND WIFE
Name\Age
Relationship
Address
Phone #

6.

Names of living parents:

  HUSBAND WIFE
Name\Age
Relationship
Address
Phone #
  HUSBAND WIFE
Name\Age
Relationship
Address
Phone #

 

III. HEALTH INSURANCE: PLEASE PROVIDE THE NAME AND ADDRESS OF THE COMPANY FOR FOLLOWING:

HUSBAND:

Medicare/Private Insurance Medicare Supplement
Company: Company:
Address: Address:
   
Long Term Care Insurance Other, Cancer, Accidental
Company: Company:
Address: Address:

WIFE:

Medicare/Private Insurance Medicare Supplement
Company: Company:
Address: Address:
   
Long Term Care Insurance Other, Cancer, Accidental
Company: Company:
Address: Address:

 

IV. PERSONAL INFORMATION
1. Have you and your spouse used your over-age 55 exemption from capital gains taxes on the sale of a residences?

2. Have arrangements been made for the disposition of your body at death?
Are they paid for? Please describe the arrangements and who they are with:


3. Are you or your spouse a veteran? If yes, did you serve in wartime? Do you currently receive any benefits? If yes, please explain:

4. Are you or your spouse at risk because of a medical condition or family history of becoming seriosuly ill or disabled or are you presently expeirence an illness? If yes, please explain:

5. Does anyone to whom you may be leaving part of your estate require help or protection in managing money or other property because he/she has a disability or is not physically responsible? If yes, explain:

V. ASSETS
 
1. Real Estate Located in Florida:
Address:
FMV:
(Indicate whether based on sales price, appraisal or tax bill)
Mortgage:
(Indicate the name of mortgage and balance of mortgage)
Title Held By:
(Indicate persons and whether title is held as tenants in common, joint tenancy with rights of survivorship, tenancy by entirety)
Homestead Exemption Filed:
 
2. Real estate located outside Florida:
Address:
FMV:
(Indicate whether based on sales price, appraisal or tax bill)
Mortgage:
(Indicate the name of mortgage and balance of mortgage)
Title Held By:
(Indicate persons and whether title is held as tenants in common, joint tenancy with rights of survivorship, tenancy by entirety)
 
3. Automobiles, Mobile Homes, Recreational Vehicles, Boats:
Type Year FMV Liens Owner
 
4. Stocks, securities, bonds, and investments:
Asset:
Name & Address of Co:
Value: Account #:
How is it titled:
When does it come due and interest rate:
 
Asset:
Name & Address of Co:
Value: Account #:
How is it titled:
When does it come due and interest rate:
 
Asset:
Name & Address of Co:
Value: Account #:
How is it titled:
When does it come due and interest rate:
 
Asset:
Name & Address of Co:
Value: Account #:
How is it titled:
When does it come due and interest rate:
 
Asset:
Name & Address of Co:
Value: Account #:
How is it titled:
When does it come due and interest rate:
 
5. Retirement and pension plans (include IRAs and 401Ks)
 
Asset:
Name & Address of Co:
Value: Account #:
How is it titled:
Taking Minimum Distribution (Y/N) Amount: Frequency:
 
Asset:
Name & Address of Co:
Value: Account #:
How is it titled:
Taking Minimum Distribution (Y/N) Amount: Frequency:
 
Asset:
Name & Address of Co:
Value: Account #:
How is it titled:
Taking Minimum Distribution (Y/N) Amount: Frequency:
 
6. Bank Acccounts:
Asset:
Name & Address of Co:
Value: Account #:
How is it titled:
When does it come due and interest rate:
 
Asset:
Name & Address of Co:
Value: Account #:
How is it titled:
When does it come due and interest rate:
 
Asset:
Name & Address of Co:
Value: Account #:
How is it titled:
When does it come due and interest rate:
 
Asset:
Name & Address of Co:
Value: Account #:
How is it titled:
When does it come due and interest rate:
 
7. Life Insurance:
  HUSBAND WIFE
Name of Owner:
Name of Insured:
Name of Insurer:
Policy #:
Face Value:
Cash Surrender Value:
Term or Whole Life:
Beneficiary (ies):
  HUSBAND WIFE
Name of Owner:
Name of Insured:
Name of Insurer:
Policy #:
Face Value:
Cash Surrender Value:
Term or Whole Life:
Beneficiary (ies):
 
8. Annuities:
Asset:
Name & Address of Co:
Value: Account #:
How is it titled:
When does it come due and interest rate:
Are there survivorship benefits and who is the beneficiary:
 
Asset:
Name & Address of Co:
Value: Account #:
How is it titled:
When does it come due and interest rate:
Are there survivorship benefits and who is the beneficiary:
 

9. Other Assets (Debts owed by others to you including description of debt, name of debtor, currnet unpaid balance, identify document which evidences debt):

Business interest in corporation or partnership (include name, address, percent of stock owned, book value and fair market vlaue of stock, whether you have a Buy/Sell Agreement, Stock Option Agreement, Deferred Compensation Agreement, or other Employee benefit plans)

 
 
Mortgages:
Promissory Notes:
Inheritance (are you receiving or do you expect to receive an inheritance in the near future), Powers of Appointment:
 
Total Of All Property:
 
VI. GROSS MONTHLY INCOME: THIS MUST INCLUDE INCOME FROM ALL SOURCES, EVEN IF REINVESTED, AS WELL AS ANY DEDUCTIONS FROM SOCIAL SECURITY OR PERNSIONS. IF YOU RECEIVE A PENSION, BRING THE BOTTOM OF YOUR MOST RECENT CHECK.
 
  HUSBAND WIFE JOINT
Social Security: $ $  
Employment: $ $  
Pensions $ $  
  From From  
  $ $  
  From From  
IRA's $ $  
Annuities $ $  
Interest on Bank Accounts, Savings Accounts, CDs $ $ $
Dividends on Stocks and Bonds $ $ $
Other (i.e. Rents) $ $ $
Total: $ $ $
 
VII. MONTHLY ESTIMATED BUDGET
Rent/Mortgage Payment/Facility: $
Utilities: $
Car Payment/Maintenance: $
Clothing: $
Food/Personal Household: $
Insurance: $
Medical Expenses (incl. Prescriptions) $
Taxes: $
Vacation/Entertainment: $
Emergency Fund: $
Other: $
Total Monthly Expenses: $
 
VIII. MONTHLY LIABILITIES
Mortgages: $
Notes to banks: $
Notes to others: $
Unpaid Medical: $
Charge card bills: $
Other: $
Total Monthly Liabilities: $
 
IX. TRANSFER OF ASSETS. THIS INFORMAITON MUST BE COMPLETED IN FULL. IF YOU DO NOT COMPLETE THIS PORTION WE WILL NOT BE ABLE TO CONDUCT THE INTERVIEW.
 
1. Have you made any gifts or transfers, of any amount, to any individuals or charities iwthin the last sixty (6) months? Yes/No: If yes, complete the following:
 
  HUSBAND   WIFE
Name of Recipient: Name of Recipient:
Date of Gift: Date of Gift:
Item Item:
Value: Value:
 
Name of Recipient: Name of Recipient:
Date of Gift: Date of Gift:
Item Item:
Value: Value:
 
Name of Recipient: Name of Recipient:
Date of Gift: Date of Gift:
Item Item:
Value: Value:
 
Name of Recipient: Name of Recipient:
Date of Gift: Date of Gift:
Item Item:
Value: Value:
 
X. LEGAL DOCUMENTS
 
A. Last Will & Testament of Husband
 
1. Name of Personal Representative:
Address of Personal Representative:
Name of Successor Personal Representative:
Address of Successor Personal Representatitive:
 

2. Name of beneficiary(ies), their address and their respective share of the estate (indicate beneficiaries who are minors and at what age they are to receive part or all of their share)

Name\Age Relationship
Address Phone #
If beneficiary predeceases you, what should happen to tis beneficiary's share?
 
Name\Age Relationship
Address Phone #
If beneficiary predeceases you, what should happen to tis beneficiary's share?
 
Name\Age Relationship
Address Phone #
If beneficiary predeceases you, what should happen to tis beneficiary's share?
 
Name\Age Relationship
Address Phone #
If beneficiary predeceases you, what should happen to tis beneficiary's share?
 
Charity Name:
Address:
Phone:
 
Charity Name:
Address:
Phone:


Is there a pre-or post-nuptial agreement?

If you have minor children, do you wish to name a pre-need guard? If so, who?

Do you wish to name a preneed guardian for yourself? If so, who?

 

Last Will & Testament of Wife

 
1. Name of Personal Representative:
Address of Personal Representative:
Name of Successor Personal Representative:
Address of Successor Personal Representatitive:
 

2. Name of beneficiary(ies), their address and their respective share of the estate (indicate beneficiaries who are minors and at what age they are to receive part or all of their share)

Name\Age Relationship
Address Phone #
If beneficiary predeceases you, what should happen to tis beneficiary's share?
 
Name\Age Relationship
Address Phone #
If beneficiary predeceases you, what should happen to tis beneficiary's share?
 
Name\Age Relationship
Address Phone #
If beneficiary predeceases you, what should happen to tis beneficiary's share?
 
Name\Age Relationship
Address Phone #
If beneficiary predeceases you, what should happen to tis beneficiary's share?
 
Charity Name:
Address:
Phone:
 
Charity Name:
Address:
Phone:


Is there a pre-or post-nuptial agreement?

If you have minor children, do you wish to name a pre-need guard? If so, who?

Do you wish to name a preneed guardian for yourself? If so, who?

 

B. Durable Power of Attorney For Husband: If you become incapacitated, do you want someone to make your financial decisions and thereby avoid a court supervised guardianship?

1. Name
Address:
Relationship:

 

2. Name
Address:
Relationship:
 
3. Indicate whether you wish to give your agent the uathority to handle the following matters:
 
Create an inter vivos trust (i.e. revocable living trust)
Make a gift (subject to restrictions)
Create or change a beneficiary designation on life insurance
Create or change a beneifciiary designation on other assets
Disclaim property to which you may be entitled
Amend, modify, revoke or terminate a trust (trust must give agent this authority as well)
Create or change rights of survivorship
Waive your right ot be a beneificiary of a joint and survivor annuity, including under a reitrement plan
Disclaim powers of appointment

B. Durable Power of Attorney For Wife: If you become incapacitated, do you want someone to make your financial decisions and thereby avoid a court supervised guardianship?

1. Name
Address:
Relationship:

 

2. Name
Address:
Relationship:
 
3. Indicate whether you wish to give your agent the uathority to handle the following matters:
 
Create an inter vivos trust (i.e. revocable living trust)
Make a gift (subject to restrictions)
Create or change a beneficiary designation on life insurance
Create or change a beneifciiary designation on other assets
Disclaim property to which you may be entitled
Amend, modify, revoke or terminate a trust (trust must give agent this authority as well)
Create or change rights of survivorship
Waive your right ot be a beneificiary of a joint and survivor annuity, including under a reitrement plan
Disclaim powers of appointment
 
4. An agent is entitled to reimbursement of expenses reasonable incurred on your behalf. A qualified agent (spouse, heir, financial institution with trust pwoers, attorney, Certified Public Accountant) is entitled to reasonable compensation unless you decide otherwise. Do you want your agent to be compensated?
 

5. The Durable Power of Attorney is effective when signed. This means if your agent gets the original or a photocopy, he/she can begin making financial decisions for you immediately even if you are healthy and not incapacitated.

Do you want to keep the orignial Durable Power of Attorney?
Do you want our law firm to hold the orignal document as your escorw agent?

 

C. Designation of Health Care Surrogate For Husband: If you ecome unconscious or unable to commmunicate, do you want osmeone to make your medical decisions and thereby avoid a guardianship?

 
1. Name of Primary Surrogate:
Address:
Telephone Office: Home:
Relationship:
 
2. Name of Primary Surrogate:
Address:
Telephone Office: Home:
Relationship:
 
3. Name(s) of those persons, other than your surrogate, who you wish to send a copy of the executed document (i.e. your treating physician, family member)

 

Designation of Health Care Surrogate For Wife: If you become unconscious or unable to commmunicate, do you want osmeone to make your medical decisions and thereby avoid a guardianship?

 
1. Name of Primary Surrogate:
Address:
Telephone Office: Home:
Relationship:
 
2. Name of Primary Surrogate:
Address:
Telephone Office: Home:
Relationship:
 
3. Name(s) of those persons, other than your surrogate, who you wish to send a copy of the executed document (i.e. your treating physician, family member)
 
 
D. Living Will For Husband: If you are diagnosed with a terminal condition and your attending physician has determined that there can be no recovery from such condition and death is imminent do you want your life prolonged?
 
1. In the event you can no longer chew food and swallow liquid orally, do you wish to receive fodo and water through artificial means such as a feeding tube surgically implanted in the stomach, an intravenous tube in the arm or, a nasogastric tube?
 
2. Do you wish to receive medication for pain even if the amount of pain medication dulls your senses?
 
3. Would you like to be cared for by Hospice. Hospice provides palliative care which includes feeding, dressing and bathing the person and administering pain medication. Hospice will not perform lfie sustaining measured such as CPR or restore breathing.
 
4. If you also have a secondary illness (i.e. pneumonia, virus, cold) do you want the secondary illness treated (treating the secondary illness will not heal or correct the terminal illness)?
 
5. If you stopped breathing or your heart stopped beating would you want to be resuscitated?
 

6. Would you like to aid medical development in the fields of tissue and organ preservaiton, transplantation of tissues and tissue culture, reconstructive medicine and surgery and the development of medical research? If your body or organs are medically acceptable, upon your death do you wish to make an anatomical gift?

If you answered yes, please answer the following:

a) I wish to give any needed organs or parts only th efollowing organs or parters: (specify organs or parts)
for the purpose of transplation, therapy, medical research, or education;

 
b) my body for anatomical study if needed. Limitations or special wishes, if any, are as follows:

 

D. Living Will For Wife: If you are diagnosed with a terminal condition and your attending physician has determined that there can be no recovery from such condition and death is imminent do you want your life prolonged?

 
1. In the event you can no longer chew food and swallow liquid orally, do you wish to receive fodo and water through artificial means such as a feeding tube surgically implanted in the stomach, an intravenous tube in the arm or, a nasogastric tube?
 
2. Do you wish to receive medication for pain even if the amount of pain medication dulls your senses?
 
3. Would you like to be cared for by Hospice. Hospice provides palliative care which includes feeding, dressing and bathing the person and administering pain medication. Hospice will not perform lfie sustaining measured such as CPR or restore breathing.
 
4. If you also have a secondary illness (i.e. pneumonia, virus, cold) do you want the secondary illness treated (treating the secondary illness will not heal or correct the terminal illness)?
 
5. If you stopped breathing or your heart stopped beating would you want to be resuscitated?
 

6. Would you like to aid medical development in the fields of tissue and organ preservaiton, transplantation of tissues and tissue culture, reconstructive medicine and surgery and the development of medical research? If your body or organs are medically acceptable, upon your death do you wish to make an anatomical gift?

If you answered yes, please answer the following:

a) I wish to give any needed organs or parts only th efollowing organs or parters: (specify organs or parts)
for the purpose of transplation, therapy, medical research, or education;

 
b) my body for anatomical study if needed. Limitations or special wishes, if any, are as follows:
 
E. Living Trust (a/k/a Revocable Trust) For Husband
1. Do you want to eliminate the need to probate your estate and have your assets distributed within a short time after your passing?
2. Name and address of Trustee or Co-Trustees:
3. Name and address of first successor trustee:
4. Name and address of second successor trustee:
5. Disposution upon death of second spouse death:
6. In the event of a beneficiary predeceases or fails to survive you, who should recieve that person's share:
7. Credit Shelter Trust:
8. Marital deduction Trust:
Living Trust (a/k/a Revocable Trust) For Wife
1. Do you want to eliminate the need to probate your estate and have your assets distributed within a short time after your passing?
2. Name and address of Trustee or Co-Trustees:
3. Name and address of first successor trustee:
4. Name and address of second successor trustee:
5. Disposution upon death of second spouse death:
6. In the event of a beneficiary predeceases or fails to survive you, who should recieve that person's share:
7. Credit Shelter Trust:
8. Marital deduction Trust:
 
 
F. DECLARATION OF DESIGNEE FOR FUNERAL ARRANGEMENTS (HUSBAND)

a. Would you like to desginate in writing a trusted individual to make or, enforce arrangements for the disposition of your body at the time of your death?

This individual would have hte authority to set the time and place of a srevice, communicate iwth a medical examiner, receive your cremains as well as take steps to enforce any anatomical gift you desire.

b. If yes, identify primary authorized representative:

Name:
Address:
Cell Phone: Work phone: Home Phone:
Relationship to you:
 
c. If yes, identify the successor authorized presentatitive:
Name:
Address:
Cell Phone: Work phone: Home Phone:
Relationship to you:
 
d. What is your preference for final arrangements? Burial? Cremation?
 
e. Detail any restrictions you want to place on the representative's authority:
DECLARATION OF DESIGNEE FOR FUNERAL ARRANGEMENTS (WIFE)

a. Would you like to desginate in writing a trusted individual to make or, enforce arrangements for the disposition of your body at the time of your death?

This individual would have hte authority to set the time and place of a srevice, communicate iwth a medical examiner, receive your cremains as well as take steps to enforce any anatomical gift you desire.

b. If yes, identify primary authorized representative:

Name:
Address:
Cell Phone: Work phone: Home Phone:
Relationship to you:
 
c. If yes, identify the successor authorized presentatitive:
Name:
Address:
Cell Phone: Work phone: Home Phone:
Relationship to you:
 
d. What is your preference for final arrangements? Burial? Cremation?
 
e. Detail any restrictions you want to place on the representative's authority:
 
G. Do you have any professional advisors who you wish us to work with? Please provide us with their names, addresses, and telephone number. If you are not currently working iwth any of teh folowing professions, would you like our office to provide you with a recommendation? (Yes or No)
Accountant:
Financial Planner:
Insurance Advisor:
 

THE ABOVE INFORMAITON IS TRUE AND CORRECT OT THE BEST OF MY KNOWLEDGE AND BELIEF.

Name:

Date:

 

Name:

Date:

 

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