Have Kids Will-Party

Contact Info:
James P. Haroutunian, Esq.
Haroutunian Law Office
630 Boston Road
Billerica, MA 01821
978-671-0711
james@hlawoffice.com
www.hlawoffice.com

Estate Planning Questionnaire for Single Persons

Dear Prospective Client:

I hope you are well. Please take a few minutes to complete this questionnaire. Effective estate planning requires the following information concerning your personal, family and financial situation be assembled. This form will aid you in organizing that information, and communicating it effectively for my review. If insufficient space is provided for any information, please include additional comments or questions in the comment field at the end of the form

As is true in any communication between a lawyer and a client, the information reported here will be held in strictest confidence and released to no one without your prior consent.

Do your best with the questionnaire and feel free to email or call me with questions at james@hlawoffice.com or (888) 671-WILL. I will review your responses and contact you shortly thereafter. Thank you.

Download Questionaire in PDF format.

I. Family Information

	Information	You
	Name
	Email Address
	Street Address
	Apt. #
	City/Town
	State
	Zip
	Home Phone
	Mobile Phone
	Work Phone
	Occupation
	Date of Birth
	List any Health Issues
	Children
1.	Child's name
	Age
	Child's Address (Town Only)
	Name of Other Parent
	Other Parent's Address (Town Only)
2.	Child's name
	Age
	Child's Address (Town Only)
	Name of Other Parent
	Other Parent's Address (Town Only)
3.	Child's name
	Age
	Child's Address (Town Only)
	Name of Other Parent
	Other Parent's Address (Town Only)
4.	Other children?	Yes No
5.	If yes, please enter their information.
	Adopted Children
1.	Child's name
	Child's address (Town only)
	Date of Adoption
	Age
2.	Child's name
	Child's address (Town only)
	Date of Adoption
	Age
3.	Child's name
	Child's address (Town only)
	Date of Adoption
	Age
4.	Other adopted children?	Yes No
5.	If yes, please enter their information.
	Disabled or Special Needs Children?
1.	Child's name
	Nature of Disability or Special Needs
	Governmental Assistance?	Yes No
	Age
2.	Child's name
	Nature of Disability or Special Needs
	Governmental Assistance?	Yes No
	Age
3.	Child's name
	Nature of Disability or Special Needs
	Governmental Assistance?	Yes No
	Age
4.	Other disabled or special needs children?	Yes No
	If yes, please provide details
	If You Have Disabled or Special Needs Children
	Do you have reason to believe your child will receive and/or be dependant on governmental assistance as an adult?	Yes No Unknown

II. Choose the Beneficiaries of your Estate

Begin with the following assumption:

You desire to leave 100% of your estate, to your children in equal shares;
Should a child predecease you, leaving children of their own (your grandchildren), these grandchildren will evenly split the deceased child’s share.

If you desire different beneficiaries, or plan to give a specific item of personal property (i.e.: Jewelry, Collectibles, etc.), please complete below:

1.	Name of Recipient
	Address (if not previously listed)
	Age (approx.)
	List specific gift or desired % of estate to be given
2.	Name of Recipient
	Address (if not previously listed)
	Age (approx.)
	List specific gift or desired % of estate to be given
	Others: list name, address, age, and gift

III. Choose Your Representative

	Executor
	EXECUTOR’S ROLE: acts as the manager of your estate when you pass away – settles debts and distributes assets through legal probate process – will be protected from liability or expense for good faith actions in this role.
	First Selection
	Name
	Address
	Second Selection
	Name
	Address

	Health Care Proxy
	HEALTH CARE PROXY’S ROLE: should you lack capacity to make medical decisions, (unconscious, coma, etc) your proxy will have such power thereby allowing them to work with your doctors. This form also designates your choice regarding artificial life sustaining treatment.
	First Selection
	Name
	Address
	Second Selection
	Name
	Address

IMPORTANT QUESTION: Do you desire prolonged artificial life-sustaining treatment, if you catastrophically lose brain function and have no medically reasonable prospect of regaining brain function or meaningful quality of life?

Yes
No

	Power of Attorney
	POWER OF ATTORNEY - ROLE: should you lack capacity to make financial decisions, (unconscious, coma, etc) the person you name can access money in your accounts and work with creditors to keep finances on track.
	Name
	Address

	Gardians for Minor Children
	GUARDIAN’S ROLE: First, if only you pass away, your child’s other parent will assume parenting duties, (if the parent’s legal custody has not been taken away). However, in the event both you and your child’s other parent pass away, your minor children’s guardian will assume responsibility for, and raise your children. The Guardian will also manage your children’s inheritance for them, using any money for their care, health and education. When selecting a guardian, consider their age, subsequent marriage, divorce, remarriage or relocation. Also, speak with them to discuss your selection and concerns.
	First Selection
	Name
	Address (Town only)
	Backup Selection
	Name
	Address (town only)

IV. Financial Information

ASSETS - Please provide a general estimate of the value, rounded to the nearest thousand or so.

	Assets	($) Owned by You
	Residence
	Other Real Estate
	Bank Accounts
	Investments
	Retirement benefits including IRAs
	Anticipated Inheritance

DEBTS - Please provide a general estimate of the value, rounded to the nearest thousand or so.

	Debts	($) Owned by You
	Real Estate Mortgages
	Loans
	Credit Cards
	Other (specify)

LIFE INSURANCE POLICIES - Please provide a general estimate of the value, rounded to the nearest thousand or so.


1.	Policy Amount ($)
	Company
	Named Insured
	Named Beneficiary
	Successor Beneficiary
2.	Policy Amount ($)
	Company
	Named Insured
	Named Beneficiary
	Successor Beneficiary
3.	Policy Amount ($)
	Company
	Named Insured
	Named Beneficiary
	Successor Beneficiary

Additional Questions or Comments: