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Estate Planning Questionnaire
Contact Information
Name
(required)
Spouse’s Name
Address
City, State & Zip
Phone
Email
(valid email required)
How many children do you have?
0
1
2
3
3+
Are any of your children under age 18?
Yes
No
Are you currently employed?
No
Retired
Self-Employed
Full-time
Part-time
Inventory of Assets
Safe Deposit Box (s)
Yes
No
Life Insurance Policy (s)
Yes
No
Real Estate in Florida
Yes
No
Real Estate outside of Florida
Yes
No
Brokerage Account (s)
Yes
No
Retirement Account (s)
Yes
No
Annuity (s)
Yes
No
Long Term Health Care Insurance
Yes
No
Checking/Money Market Account (s)
Yes
No
Savings Account
Yes
No
Certificate(s) of Deposit
Yes
No
Automobile (s)
Yes
No
Current Estate Plan
Pick One
None
Will prepared within past 5 years
Will prepared more than 5 years ago
Revocable Trust prepared within past 5 years
Revocable Trust prepared more than 5 years ago
Have arrangements been made for any of the following?
Durable General Power of Attorney
Yes
No
Health Care Surrogate Designation
Yes
No
Living Will Declaration
Yes
No
What would be the most convenient time for us to contact you?
Morning
Afternoon
Evening
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