CONFIDENTIAL ESTATE PLANNING QUESTIONNAIRE

Date: ______________________ Referred by:_______________________________

Name: ___________________________________________________________________________________________

Address: __________________________________________________________________________________________

Phone: Home____________________ Work____________________ Cell__________________ Fax_________

Email: Personal__________________ Work____________________

Occupation:______________________________________ Resided in Florida since _____ Age_________

Have you ever made a will or a trust?______________ Safe deposit box is at__________________________ Bank
(If so, please bring it in)

Citizen of U.S. ___; Other:_________ Accountant:_______________________________________

Life Insurance Agent:____________________________

Stock Broker: _____________________________________

FAMILY INFORMATION Name Address Phone Age

Spouse

Children

Spouse's Children

Parents

Spouse's Parents

Brothers & Sisters

Spouse's Brothers
& Sisters

Persons Not Listed Above
To Whom You Want To Leave Something
NOTE: We will discuss all of the following questions in more detail. Please answer as best as you can for now.

REPRESENTATIVE INFORMATION
Who do you want to act for you in case of your death or incapacity? Please list alternates.

ASSET INFORMATION
(Just estimate values) Your Name Alone, Joint with Spouse, Spouse's Name Alone

Life Insurance

Home

Other Real Estate

Stocks, Bonds, Etc.

Bank, Savings, CD's,
Money Markets, Etc.

IRA's, Retirement Accts, Etc.

Furnishings, Jewelry,
Autos, & Tangible Property

Inheritances Expected

Other Assets

Totals

WILL AND TRUST DISPOSITIVE INFORMATION

(Please list to whom you want to leave your assets at your death. Please list alternates to receive each gift in case the person you name dies before you.)

Special gifts of jewelry, furnishings, autos, collections and other tangible property:
(Please state whether the cost of delivery should be paid by the estate or by the beneficiary)

Gift of all remaining tangible property:

Gift of homestead:

Special gifts of cash, stock or other specific items:

Gift of all remaining assets (residue):

TRUSTS FOR MINORS OR OTHERS

List anyone (such as minor children) for whom you want assets held in trust instead of being distributed to them at your death, so that the trustee invests and distributes the assets on a certain schedule until the beneficiaries can do so alone?

Who do you want to be the trustee (may be bank or individual)?
(Please list alternates)

List at what age you want the beneficiary to begin directly receiving income from the trust (e.g, age 21):

List at what age(s) you want the beneficiary to receive the principal (e.g., in thirds at ages 25, 30 and 35):

ESTATE PLANNING DOCUMENTS

In addition to discussing your last will and testament...

Do you want to discuss the effect of holding assets in joint names or "in trust for" with others?
______ Yes ______ No

Do you want to discuss setting up a living trust?
______ Yes ______ No

Do you want to discuss giving someone your durable power of attorney to handle your financial affairs and bill paying?
______ Yes ______ No

Do you want to discuss signing a living will to express your desires concerning the use or non-use of medical procedures to prolong your life in case of terminal illness?
______ Yes ______ No

Do you want to discuss signing a designation of health care surrogate to give someone power to make medical decisions for you if you are unable to do so?
______ Yes ______ No

Do you want to discuss signing a declaration of preneed guardian in case a court finds you or your minor child incapacitated?
______ Yes ______ No

Do you want to discuss anything else? Please list:

*****************************************************
Return to:
James W. Martin, P.A.
Attorney at Law

Hand delivery:
Palais Royale Building, Suite 310A
146 Second Street North
St. Petersburg, Florida 33701

US Mail:
PO Box 1324
St. Petersburg, FL 33731-1324

Email: jim@jamesmartinpa.com

Fax: (727) 823-3479

If questions, call: (727) 821-0904

2012.02.26