Confidential Estate Planning Survey Form

We recognize that this information is of a personal nature. All information provided to this office by you will be treated confidentially and will not be revealed to anyone outside of this office without your permission.

SECTION 1: GENERAL INFORMATION

Your Name (for legal documents)  
Mailing Address
City
State
Zip
County of Residence
Home Phone
Work Phone
Cell Phone
Date of Birth
Soc. Sec. #
Employer
Job Title
Email Address  
If Married
Name of Person who referred you to this firm
Date of Marriage
Place of Marriage
Spouse Name
Date of Birth
Soc. Sec. #
Employer
Job Title
Email Address
Information of person filling out this form (if other than client)
Name
Street Address
City
State
Zip
County of Residence
Home Phone
Work Phone
Cell Phone
Email Address
CHIILDREN (if applicable)
Child 1
Street Address
City
State
Zip
Home Phone with area code
Work Phone with area code
Cell Phone with area code
Date of Birth
Email Address
Child 2
Street Address
City
State
Zip
Home Phone with area code
Work Phone with area code
Cell Phone with area code
Date of Birth
Email Address
Child 3
Street Address
City
State
Zip
Home Phone with area code
Work Phone with area code
Cell Phone with area code
Date of Birth
Email Address
Child 4
Street Address
City
State
Zip
Home Phone with area code
Work Phone with area code
Cell Phone with area code
Date of Birth
Email Address
Child 5
Street Address
City
State
Zip
Home Phone with area code
Work Phone with area code
Cell Phone with area code
Date of Birth
Email Address
Child 6
Street Address
City
State
Zip
Home Phone with area code
Work Phone with area code
Cell Phone with area c ode
Date of Birth
Email Address
OTHER DEPENDENTS (if applicable)
Full Name  
Date of Birth
Relationship
Email Address
Full Name
Date of Birth
Relationship
Email Address  
GENERAL QUESTIONS
YOU:
Presently have a will? Yes No
Presently have a trust? Yes No
Presently have a power of attorney? Yes No
Presently have a Living Will? Yes No
Presently have a Health Care Proxy? Yes No
US Citizen Yes No
Expecting to receive an inheritance? Yes No
Is this your first marriage? Yes No
Any dependents with special needs? Yes No
Would any of your heirs contest your wishes? Yes No
Have long-term care insurance? Yes No
SPOUSE (if applicable)
Presently have a will? Yes No
Presently have a trust? Yes No
Presently have a power of attorney? Yes No
Presently have a Living Will? Yes No
Presently have a Health Care Proxy? Yes No
US Citizen Yes No
Expecting to receive an inheritance? Yes No
Is this your first marriage? Yes No
Any dependents with special needs? Yes No
Would any of your heirs contest your wishes? Yes No
Have long-term care insurance? Yes No

SECTION 2: DOCUMENTS TO BRING TO YOUR CONSULTATION

Real Estate Deeds and Current Tax Bills Wills and trusts Living Wills/Health Care Proxies Powers of Attorney

SECTION 3: TRUSTEES, PERSONAL REPRESENTATIVES, BENEFICIARIES

Person(s) who will be named as Trustee(s) or Personal Representative(s) of your estate:
Person 1
Street Address
City
State
Zip
Email Address
Person 2
Street Address
City
State
Zip
Email Address
Person 3
Street Address
City
State
Zip
Email Address
Person 4
Street Address
City
State
Zip
Email Address
Person(s) who will be named Beneficiarie(s) of your estate:
Person 1
Street Address
City
State
Zip
Email Address
Person 2
Street Address
City
State
Zip
Email Address
Person 3
Street Address
City
State
Zip
Email Address
Person 4
Street Address
City
State
Zip
Email Address

SECTION 4: FINANCIAL INFORMATION

This is a general overview of your assets. Values should be approximate and are needed only to assist in your tax planning.
IRAs, Pensions, Retirement Plans, Tax-Deferred Annuities
Type 1
How Titled
Approx. Value in $
Type 2
How Titled
Approx. Value in $
Type 3
How Titled
Approx. Value in $
Non-Tax Deferred Bank Accounts (including CDs, money markets)
Bank Account 1
How Titled
Approx. Value in $
Bank Account 2
How Titled
Approx. Value in $
Bank Account 3
How Titled
Approx. Value in $
Brokerage Accounts
Brokerage 1
How Titled
Approx. Value in $
Brokerage 2
How Titled
Approx. Value in $
Brokerage 3
How Titled
Approx. Value in $
Stocks/Mutual Funds/Bonds (those held individually, not with a broker)
Type
How Titled
Approx. Value in $
Type
How Titled
Approx. Value in $
Annuities
Annuity 1
How Titled
Approx. Value in $
Annuity 2
How Titled
Approx. Value in $
Mortgages, Notes (Money owed TO you)
Note 1
How Titled
Approx. Value in $
Note 2
How Titled
Approx. Value in $
Extraordinary Valuables (antiques, art, etc.)
Valuables 1
How Titled
Approx. Value in $
Valuables 2
How Titled
Approx. Value in $
Valuables 3
How Titled
Approx. Value in $
Real Estate Owned (bring tax bills and deeds to your consultation)
Real Estate 1
How Titled
Mortgage Amount
Approx. Value in $
Real Estate 2
How Titled
Mortgage Amount
Approx. Value in $
Real Estate Owned (bring tax bills and deeds to your consultation)
Real Estate 1
How Titled
Mortgage Amount
Approx. Value in $
Real Estate 2
How Titled
Mortgage Amount
Approx. Value in $
Life Insurance Policies
Company 1
Owner
Insured Party
Approx. Value in $
Company 2
Owner
Insured Party
Approx. Value in $
General Information
Monthly Income
Approx. Total Gross Estate

Section 5: Your Questions

List any specific concerns and questions you would like to address during your consultation:
Please tell us how you learned about The Karp Law Firm: