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msword - DSouza Law Office, LLC

By Herman Watson,2014-07-10 18:06
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msword - DSouza Law Office, LLC ...

    D’Souza Law Office LLC

    7979 Old Georgetown Road, Suite 1100

    Bethesda, Maryland 20814

    (301) 452-1888

    The Purpose of this Questionnaire

     Please keep in mind when completing this questionnaire that estate planning requires a

    thorough analysis of your estate by yourself and your attorney. The information you provide will

    enable your attorney to determine the documents necessary to fulfill your estate planning goals. It

    may also provide helpful information to the person you seek to be your Personal Representative

    after your death or your Power-of-Attorney during your lifetime.

     Please fill these documents to the best of your ability, and indicate if you are uncertain

    about your answer to any question. All information provided shall be kept confidential.

    Notice Regarding Joint Representation of Married Couples or Domestic Partners

     If you are married or have a domestic partner, please be advised that you both have the

    option of obtaining a separate attorney for your estate planning needs. The goals of many couples

    are the same when it comes to wills and estate planning. However, many individuals (especially

    individuals that have children from prior marriages) have differing views on the ownership of

    property, the identity of beneficiaries, the identity of executors, trustees and guardians, etc. If both

    of you were to obtain a different attorney, you would receive completely independent and

    confidential advice.

    In representing you jointly, this law practice’s advice will be directed to you jointly and

    nothing will be kept confidential as between the two of you. If you are unsure of whether you want

    to obtain separate attorneys, this law practice would be happy to discuss the matter with you in

    more detail before you make your decision.

     Please note a substantial conflict may exist in the determination of what constitutes

    community property and what is separate property. That determination may be more beneficial for

    one of you than for the other. Although unlikely, the possibility of a divorce must also be

    recognized. Consequently, the law practice’s present recommendations could affect the income,

    property, and support provision in any such divorce or after the death of one or both of you.

ESTATE PLANNING QUESTIONNAIRE

     Date:__________________ Your Full Name:_________________________ Other Names Used:____________________ I. FAMILY HISTORY Home Address:__________________________ Home Phone: ________________________ County:________________________________ Cell Phone:__________________________ E-Mail:________________________________ Best Method Of Contact:________________ Date Of Birth:___________________________ Place Of Birth:________________________ Social Security No.: ______________________ Citizenship:__________________________ Spouse’s Full Name:______________________ Other Names Used:____________________ Date Of Birth:___________________________ Place Of Birth: _______________________ Date Of Marriage: _______________________ Place Of Marriage: ____________________ Social Security No. :______________________ Citizenship:__________________________ If married, have you and your spouse lived or owned property in a community property state?

     Yes No. If yes, please circle state(s): Arizona, California, Idaho, Louisiana, Nevada, New Mexico,

    Texas, Washington, Wisconsin Children and Deceased Children

    Name Of Child 1:

    Other Names Used:

    Date Of Birth:

    Social Security No.:

Adopted Or Child Only Of One Spouse:_______________________________________________________

    Address:

    Phone:

    Spouse’s Name:

    Name And Date Of Birth Of Each Child’s Child:

    Name Of Child 2:

    Other Names Used:

    Date Of Birth:

    Social Security No.:

Adopted Or Child Only Of One Spouse:_______________________________________________________

    Address:

    Phone:

    Spouse’s Name:

Name And Date Of Birth Of Each Child’s Child:

Are any children (natural or adopted) anticipated? Yes No

    Please note “children” as used in the will shall include any children born or adopted after the making of the will, but

    not step-children.

Do you or your spouse have any other dependents for support now or in the future?

     ________________________________________________________________________________________________________________________________________________________________________

    Do you, your spouse, or your children have any special medical, educational, or financial needs? Yes No

     If yes, please describe___________________________________________________________________________

Do you or your spouse need skilled nursing care and related services, rehabilitation services, or health related services

    above the level of room and board? Yes No

     Is care needed on a daily basis? Yes No

     Is care required to be provided on an inpatient basis? Yes No

     Is care provided by a facility that is certified for participation in Medicaid? Yes No

     Is care ordered by and provided under the direction of a physician? Yes No Please explain any other special medical, educational or financial needs, for you, your spouse, or your children and how you would like to provide for them.

    ______________________________________________________________________________________

Prior Marriage SELF SPOUSE

    Former Spouse’s Name _____________________ __________________________

    Date of Marriage___________________________ ________________________

    Place of Marriage: _________________________ ________________________

    Date of Death/Divorce:______________________ ________________________

     Court_______________________ _______________________

Do you have a marital or property settlement agreement? Yes No. If yes, please attach.

Do you have an prenuptial agreement? Yes No. If yes, please attach.

Do you have a domestic partnership agreement? Yes No. If yes, please attach.

    Do you have any child support, alimony, insurance, or other obligations? Yes No. If yes, what is the obligation and how much is the monthly amount required?___________________________________ Others Are there any other individuals or charitable organizations that you would like to named beneficiaries? Other Persons: Address and Phone Number Age: Relationship, if any ________________ ____________________________ _______ ___________________ ________________ ____________________________ _______ ___________________ Charity Address and Phone Number ________________ ________________________________________________________________ ________________ ________________________________________________________________

    Contacts

Accountant:__________________________________________________________________

Insurance Agent:______________________________________________________________

Broker/Investment Advisor:_____________________________________________________

     Financial Planner:_____________________________________________________________

II. DISTRIBUTION OF ESTATE

    Prior Estate Planning Self Spouse

    Do you have an existing will? Yes No Yes No Do you have a Power of Attorney? Yes No Yes No Do you have a living will/advanced directive? Yes No Yes No

If you have any previous estate planning documents, please bring them with you.

     Funeral Arrangements: Would you prefer cremation/normal burial? _____________________________________________

    Have you made burial arrangements? Yes No. If yes, please identify cemetery plot and location & custody of

    deed ___________________________________________________________________

Your New/Revised Estate Plan

How are the personal effects and other tangible personal property to be distributed (please check)?

    All to the spouse? Yes No

    All to the children? Yes No

Do you have any special bequests of property? Yes No

    Description of Property Name of Beneficiary

    _____________________________ _______________________________

    _____________________________ _______________________________

    How is the division of remainder property to be made?

____________________________________________________________________________________________

    ____________________________________________________________________________________________

    ____________________________________________________________________

     Your second choice as to division of the remainder property (in case named primary beneficiary/ies is/are not alive or disclaims/disclaim interest to the property)?

    ____________________________________________________________________________________________

    ____________________________________________________________________________

    If you (and, if you are married, your spouse) were both to die prematurely, when should your children receive their

    inheritance?

     at age 18

     at age 21

     at age 25

     at age 30

     one-half at age 21, with the remainder at age 25.

     one-third at 21, one-third at age 25, and the remainder at age 30

     one-third at 25, one-third at age 30, and the remainder at age 35

     other

    ________________________________________________________________________________________

Do you want to provide encouragement/recognition upon milestone events if you are not alive to make a gift.

    Amount to be distributed

    A. 2 year college degree or its equivalent $ __________________________________

    B. 4 year college degree or its equivalent $ __________________________________

    C. Master’s degree or its equivalent $ __________________________________

    D. Doctorate’s degree or its equivalent $ __________________________________

    E. Upon a first marriage $ __________________________________

Do you intend to remain in the State of Maryland? Yes No

    Do you own any real estate in the District of Columbia? Yes No

    Does either spouse intend to seek employment after the death of a spouse? Yes No Are you or your spouse named as a beneficiary in any trust or will? Yes No Do you or your spouse have any power of appointment under a trust or will? Yes No Have you or your spouse ever filed a gift tax return (IRS Form 790)? Yes No. If yes, please attach.

Do you have long term care health insurance? Yes No

III. PERSONS RESPONSIBLE

Guardian For Minor Children (Under Age 18)

    A guardian provides shelter, education and care for the minor in place of the parent.

    First choice: (Do not name spouse or other parent, that will be assumed) Full Name:___________________________________________________________ Address______________________________________________________________ Relationship__________________________________________________________ Second choice:________________________________________________________ Full Name____________________________________________________________ Address/Phone No.________________________________________________________ Relationship__________________________________________________________ Trustee in Will

    A trustee maintains funds for a minor child and/or adult child with spendthrift problems.

    First choice: (Do not name spouse or other parent, that will be assumed) Full Name:___________________________________________________________ Address/Phone No.___________________________________________________ Relationship__________________________________________________________ Second choice:________________________________________________________ Full Name____________________________________________________________ Address/Phone No.________________________________________________________ Relationship__________________________________________________________ Personal Representative(Executor) In A Will. Personal representative opens the estates, maintains records of the

    estate, and files financial accountings with the court.

First choice:

    Full Name:___________________________________________________________________________ Address/Phone:_______________________________________________________________________ Relationship__________________________________________________________________________ Second choice:________________________________________________________________________ Full Name___________________________________________________________________________ Address/Phone:_______________________________________________________________________ Relationship_________________________________________________________________________ Unless you specifically designate otherwise, these provisions are included: A. Broad powers for the Executor and the Trustee.

    B. No bond to be required for the Executor or the Trustee.

    IV. SUMMARY OF ASSETS

To properly advise you of potential tax problems as well as trust applications, the following

    disclosure of information is required. Estimates will be sufficient. Use fair market values, free from mortgage

    and liens.

     SUMMARY

    ESTATE OF DATE

ASSETS YOUR IN JOINT

     SPOUSE’S

    NAME NAME NAME

    1. REAL ESTATE EQUITY ......................

     .............................................................

    2. STOCKS ...............................................

    3. BONDS.................................................

    4. CASH (AVERAGE BALANCE) ............

    5. MORTGAGES & NOTES .....................

    6. LIFE INSURANCE ...............................

    7. PERSONAL PROPERTY ......................

    8. RETIREMENT ......................................

    9. PENSION (DEATH BENEFITS) ...........

    10. PROFIT-SHARING PLAN ....................

11. BOOK VALUE OF BUSINESS ASSETS

    FROM BALANCE SHEET DATED ......

    12. GIFTS RECEIVED DURING LIFE .......

    13. POWERS OF APPOINTMENT .............

    14. ANNUITIES..........................................

    15. ANTICIPATED INHERITANCES .........

    16. MISCELLANEOUS ..............................

     .............................................................

    TOTAL ASSETS..........................................

LIABILITIES

1. CURRENT DEBT, INCLUDING MORTGAGES__________________________________________

     Do you have mortgage life insurance?

     Yes No

2. INSTALLMENT CONTRACTS…………________________________________________________

    3. PERSONAL LOANS/COLLATERAL……………………___________________________________

     IF YOU HAVE ANY OF THE FOLLOWING TYPE OF DOCUMENTS, PLEASE BRING THEM

    WITH YOU TO THE INITIAL CONSULTATION:

     PREVIOUS WILLS AND CODICILS, TRUSTS, LIVING WILLS, OR HEALTH CARE DIRECTIVES

     ANTE-NUPTIAL OR PROPERTY SETTLEMENT AGREEMENT

     RECENT STATEMENT OF ALL BANK OR INVESTMENT ACCOUNTS

     RECENT STATEMENT OF PENSION, PROFIT-SHARING, OR OTHER RETIREMENT PLANS

     DEEDS AND MORTGAGES FOR ALL REAL ESTATE

     COPIES OF ALL GIFT TAX RETURNS

V. ADDITIONAL ESTATE PLANNING DOCUMENTS

Durable Power Of Attorney For Financial Matters

    A durable power of attorney is frequently given to your spouse, an adult child, or another relative or trusted friend authorizing that person (called your "attorney-in-fact") to act on your behalf and sign your name to legal and/or financial documents. If you have not given a durable power of attorney to anyone, you may wish to consider doing so as part of your estate planning process, as the durable power of attorney can be a very valuable tool in the event that, due to age, illness, or injury, you are unable to carry on your personal and financial affairs, someone would have to go to court to have you declared mentally or physically incompetent and be appointed to serve as your legal guardian. This process is time-consuming, expensive, and publicly embarrassing.

     I have already had this type of document prepared and do not wish to revise it at this time. (A) Attorney-In-Fact (Name, Address, And Telephone Number): ____________________________________________________________________________________________ ____________________________________________________________________________________________ (B) Back-Up Attorney-In-Fact (Name, Address, And Telephone Number): ____________________________________________________________________________________________ ____________________________________________________________________________________________

Advanced Directive

    An advanced directive (also known as a living will) authorizes another person (called your "health care agent") to make

    decisions with respect to your health care in the event that you are physically or mentally unable to do so. This

    document also serves to indicate your wishes concerning the use of artificial or extraordinary measures to save you life

    in the event of a terminal illness or injury. You can also use this document to indicate you wishes with regard to organ

    donation, disposition of bodily remains, and funeral arrangements.

     I have already had this type of document prepared and do not wish to revise it at this time.

     (A) Primary Agent (Name, Address, And Telephone Number): (B) ALTERNATE AGENT (NAME, ADDRESS, AND TELEPHONE NUMBER) (or _______ joint agent)

List persons not to be involved in decision making

    TIME OF EFFECTIVENESS (choose one, A is preferred) A) Advanced Directive is effective when signed.

    B) Advanced Directive is not effective until grantor is disabled (when 2 physicians state under oath that they have

    personally examined the grantor). Please review the following to determine the type of treatment to be provided when one is in a persistent vegetative

    state, terminal condition, and end-stage condition.

    ? Persistent Vegetative State means a condition caused by injury, disease, or illness, in which a patient has suffered a loss of consciousness, exhibiting no behavioral evidence of self awareness or awareness of surroundings in a

    learned manner other than reflex activity of muscles and nerves for low level conditioned response and from which,

    after the passage of a medically appropriate period of time, it can be determined to reasonable degree of medical

    certainty, that there can be no recovery.

    ? Terminal Condition means an incurable condition caused by injury, disease, or illness which, to a reasonable degree of medical certainty, makes death imminent and from which, despite the application of life-sustaining

    procedures, there can be no recovery.

    ? End Stage Condition means an advanced, progressive, irreversible condition caused by injury, disease, or illness that has caused severe and permanent deterioration indicated by incompetency and complete physical dependency and

    for which to a reasonable degree of medical certainty, treatment of the irreversible condition would be medially

    ineffective.

    Instructions to Agent as to providing, withdrawing, or withholding life-sustaining treatment Complete the blocks below by choosing one of the following numbers for each block:

    1.Yes, always provide 2. Yes, provide for _______ days 3. No, never provide

    Medical Surgery CPR Mechanical Dialysis Antibiotics Tube Chemotherapy and Condition Ventilation Feeding Radiation

     Terminal

    Condition

     Persistent

    Vegetative

    State

     End Stage

    Condition

PAIN MEDICATION

    Do you authorize your agent to request pain medication and surgical intervention to relieve your pain?

     Yes No

     ANATOMICAL GIFTS/ORGAN DONATIONS

    Do you authorize your agent to donate your organs? Yes No

    If yes, please answer the following:

    I direct that if I am “brain dead”, an anatomical gift be offered on my behalf to a patient in need of organ or tissue

    transplant. If a transplant occurs, I want artificial heart lung support devices to be continued in my behalf only until

    organ or tissue suitability of the patient is confirmed and organ or tissue recovery has taken place. Yes No

     PREGNANCY (Choose One)

    A) If I am pregnant my decision concerning life-sustaining procedures is not modified. B) If I am pregnant I direct that my life be extended by life-sustaining procedures until such time as the child is born.

C) Not applicable.

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