Estate Planning Questionnaire Form

General

First Name*

Middle Initial*

Last Name*

Maiden Name

This field is hidden when viewing the form

Legal Name*

First Name

Middle Initial

Last Name

(Maiden Name)

Last 4 Digits of SS #*

Birth Month

Day

Year

Are you an Arizona resident?*

Yes

No

If not a U.S. Resident, what is your country of citizenship?

Contact Information

Email Address*

Cell Phone*

Home Phone

Permanent Home Address*

Address City State Zip Country

Employment

Employer

Job Title

Work Address

Address City State Zip Country

Family and Partnership

Are there any minor children?

No

Yes

Do you have a spouse or domestic partner?*

No

Yes

Are you legally married?*

No

Yes

Place of Marriage (City/State/Country)

Marriage Date - Month

Marriage - Year

Spouse or Partner

First Name*

Middle Initial*

Last Name*

Maiden Name

This field is hidden when viewing the form

Spouse Legal Name*

First Name

Middle Initial

Last Name

(Maiden Name)

Last 4 Digits of Social Security Number*

Birth Month

Day

Year

Number of years as an Arizona Resident

If not a U.S. Resident, what is your country of citizenship?

Spouse/Partner Contact Information

Email Address*

Cell Phone*

Home Phone

Fax Number

Spouse/Partner Employment

Employer

Job Title

Work Address

Address City State Zip Country

* Please use mm/dd/yy format for any date listings.

Your Living Parents

Full Name

Date of Birth (mm/dd/yy)

Spouse's Living Parents

Full Name

Date of Birth (mm/dd/yy)

Your Living Siblings

Full Name

Date of Birth (mm/dd/yy)

Spouse's Living Siblings

Full Name

Date of Birth (mm/dd/yy)

Children (including natural and adopted)

Full Name

Date of Birth (mm/dd/yy)

From prior relationship? (y/n)

Please list all persons or charitable organizations who will inherit estate property

Full Name

Address

Notes (for attorney use)

PRIMARY Successor Trustee for a Family Trust

The general duty of a Successor Trustee is to administer the provisions of the trust in a timely manner for the benefit of the beneficiaries. You and your spouse/partner are the initial Trustees. Your Successor Trustee steps in upon your deaths or incapacity.

Is bond or other security required of successor trustee?

Yes

No

Your Primary Successor Trustee Full Name

Relationship to you

Please clarify

ALTERNATE Successor Trustee

(If your Primary Successor Trustee cannot perform his/her duties for whatever reason, your Alternate Representative would assume those duties.)

Your Alternate Successor Trustee Full Name

Relationship to you

Please clarify

Do you have additional alternate Successor Trustees?

No

Yes

Your Additional Alternate Successor Trustees

Full Name

Relationship to Client

PRIMARY Guardian for Minor Children

(A surviving spouse would typically be the guardian of any minor children. If there is no surviving spouse, another guardian(s) should be named.)

Your Primary Guardian Full Name

Relationship to you

Please clarify

Your Primary Guardian Address

City State Country

ALTERNATE Guardian for Minor Children

(If your Primary Guardian for Minor Children cannot perform his/her duties for whatever reason, your Alternate Representative would assume those duties.)

Your Alternate Guardian Full Name

Relationship to you

Please clarify

Your Alternate Guardian Address

City State Country

Do you have additional alternate Guardians?

No

Yes

Your Additional Alternate Guardians

Full Name

Relationship to Client

Full Address

PRIMARY Agent for Financial Power of Attorney

(Person to make financial decisions on your behalf)

My Spouse/Partner will be my Primary Agent for Financial Power of Attorney

(Same contact information indicated previously)

Yes

No

Your Primary Agent Full Name

Relationship to you

Please clarify

Will you serve as Primary Agent for your Spouse/Partner?

Yes

No

Spouse/Partner Primary Agent Full Name

Relationship to spouse/partner

Please clarify

ALTERNATE Agent for Financial Power of Attorney

(If your Primary Agent for Financial Power of Attorney cannot perform his/her duties for whatever reason, your Alternate Representative would assume those duties.)

Your Alternate Agent Full Name

Relationship to you

Please clarify

Do you have additional alternate agents?

No

Yes

Your Additional Alternate Agents

Full Name

Relationship to Client

Spouse Alternate Agent Full Name

Relationship to Spouse/Partner

Please clarify

Does your spouse have additional alternate agents?

No

Yes

Spouse Additional Agents

Full Name

Relationship to Client

PRIMARY Health Care Agent

(Person to make health care decisions on your behalf if you are unable)

My Spouse/Partner will be my Primary Health Care Agent

(Same contact information indicated previously)

Yes

No

Your Primary Health Care Agent Full Name

Relationship to you

Please clarify

Agent Cell Phone*

Agent Home Phone

Your Primary Health Care Agent Address*

Address City State Zip Country

Will you serve as Primary Health Care Agent for your Spouse/Partner?

Yes

No

Spouse/Partner Primary Health Care Agent Full Name

Relationship to Spouse/Partner

Please clarify

Cell Phone*

Home Phone

Spouse/Partner Primary Health Care Agent Address*

Address City State Zip Country

ALTERNATE Health Care Agent

(If your Primary Health Care Agent cannot perform his/her duties for whatever reason, your Alternate Representative would assume those duties.)

Your Alternate Health Care Agent Full Name

Relationship to you

Please clarify

Cell Phone

Home Phone

Your Alternate Health Care Agent Address

Address City State Zip Country

Do you have additional alternate Health Care Agents?

No

Yes

Your Additional Alternate Health Care Agents

Full Name

Relationship to Client

Preferred Phone Number

Full Address

Spouse Alternate Health Care Agent Full Name

Relationship to Spouse/Partner

Please clarify

Cell Phone

Home Phone

Spouse Alternate Health Care Agent Address

Address City State Zip Country

Does your spouse have additional alternate Health Care Agents?

No

Yes

Spouse Additional Alternate Health Care Agents

Full Name

Relationship to Client

Preferred Phone Number

Full Address

Property and Liabilities

Please list all applicable items in the fields below.

Click the "+" icon to add items.

Cash and Deposit Bank Accounts

Item (Type of Account)

Bank or Financial Institution

Approximate Value

IRA's and SEP IRA's

Item

Bank or Financial Institution

Approximate Value

Other Property & Assets

Stocks, Bonds, Notes, Mortgages paid to you, Deeds of Trust

Item

Approximate Value

Business Entities (LLCs or Corporations)

Item

State Entity Was Formed

% Ownership

Life Insurance

Item

Approximate Value

Retirement Plans

Item

Approximate Value

Motor Vehicles You Own

Year/Make/Model

Approximate Value

Liens? (yes/no)

Real Property

(Homes, land and other real estate that you own)

Address or Location

Approximate Value

Amount Owed

Liabilities

Item

Approximate Value

Form Submission

Please tell us who referred you to our firm (or how you found us)

Yes, I understand submitting this form does not create an attorney-client relationship. By submitting, I am consenting to Loose Law Group, P.C. contacting me.

Estate Planning Questionnaire Form

General

Contact Information

Employment

Family and Partnership

Spouse or Partner

Spouse/Partner Contact Information

Spouse/Partner Employment

PRIMARY Personal Representative

ALTERNATE Personal Representative

PRIMARY Successor Trustee for a Family Trust

ALTERNATE Successor Trustee

PRIMARY Guardian for Minor Children

ALTERNATE Guardian for Minor Children

PRIMARY Agent for Financial Power of Attorney

ALTERNATE Agent for Financial Power of Attorney

PRIMARY Health Care Agent

ALTERNATE Health Care Agent

Property and Liabilities

Form Submission

Scottsdale

Tucson

Paradise Valley

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