1PERSONAL INFORMATION

2FAMILY

3PRIMARY BENEFICIARIES

4FIDUCIARIES

The information you provide on this form is an important beginning for us to gather the information necessary to gather the information necessary to finalize your plan details.

Do not worry if you are unable to answer all of the questions below. We will discuss your plan and nominees in more detail during your next meeting.

We appreciate you taking the time to give us this confidential information—it will be kept in strict confidence.

PERSONAL INFORMATION

DATE COMPLETED

Marital Status(Required)

Client 1 Details

CLIENT 1 FULL LEGAL NAME*(Required)

Birthdate

Name you prefer to be called by

SSN: We will gather this information at our next meeting

How do you sign legal documents?

(i.e., John Doe, John A. Doe, John Alan Doe)

Employer Name

Occupation

(if retired, former occupation)

Phone

Address

Email Address(Required)

Client 2 Details

CLIENT 2 FULL LEGAL NAME*(Required)

Birthdate

Name you prefer to be called by

SSN: We will gather this information at our next meeting

How do you sign legal documents?

(i.e., John Doe, John A. Doe, John Alan Doe)

Employer Name

Occupation

(if retired, former occupation)

Phone

Address

Email Address(Required)

RESIDENCE

Street Address

Mailing address

Additional/Seasonal Address

MARRIAGE

If married, date of current marriage

State where married

Prenuptial agmt?

Yes

Previous marriages

Name of former spouse

Year marriage ended

Previous marriages of Spouse

Name of former spouse

Year marriage ended

PRIMARY BENEFICIARIES

Please provide contact information for any individuals and/or charities, not already listed above, to you whom wish to leave inheritance upon your death.

Individual 1 Detail

Name

Gender

Male

Female

Address

Best contact phone number(s)

Relationship to you (i.e. Friend, Cousin, Sister, etc…)

Individual 2 Detail

Name

Gender

Male

Female

Address

Best contact phone number(s)

Relationship to you (i.e. Friend, Cousin, Sister, etc…)

Individual 3 Detail

Name

Gender

Male

Female

Address

Best contact phone number(s)

Relationship to you (i.e. Friend, Cousin, Sister, etc…)

Individual 4 Detail

Name

Gender

Male

Female

Address

Best contact phone number(s)

Relationship to you (i.e. Friend, Cousin, Sister, etc…)

DISTRIBUTIONS TO BENEFICIARIES Timing & Amounts

Think about the percentages/shares you want to distribute to each beneficiary and whether a distribution to all or some of the beneficiaries should be spread out over a period of years. Provide details and or/concerns regarding distribution timing and amounts for further discussion at our next meeting:

Monday	9:00 AM - 5:00 PM
Tuesday	9:00 AM - 5:00 PM
Wednesday	9:00 AM - 5:00 PM
Thursday	9:00 AM - 5:00 PM
Friday	9:00 AM - 5:00 PM

CONFIDENTIAL QUESTIONNAIRE ESTATE PLANNING INFORMATION FORM

PERSONAL INFORMATION

Client 1 Details

Client 2 Details

RESIDENCE

MARRIAGE

Previous marriages

Previous marriages of Spouse

FAMILY / BENEFICIARY INFORMATION

CHILDREN (Please write "dec" after name if child is deceased)

Child 1

Child 2

Child 3

Child 4

Child 5

Child 6

Additional Children Information

PRIMARY BENEFICIARIES

Individual 1 Detail

Individual 2 Detail

Individual 3 Detail

Individual 4 Detail

DISTRIBUTIONS TO BENEFICIARIES Timing & Amounts

FIDUCIARIES

MONEY MANAGEMENT & ESTATE ADMINISTRATION

HEALTH CARE AGENTS

GUARDIANS FOR MINOR CHILD(REN)

Neyens Law PLLC

Office Hours

By Appointment Only

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