ATTORNEY DEBORAH A. RUDOLF
P.O Box 1537
114 State Road, Suite A1
Sagamore Beach, MA 02562
Tel: 508.888.1108
Fax: 508.888.1103
This questionnaire is confidential and is meant to help me identify the most important issues that should be discussed at our estate planning conference. For the financial questions, I only need very rough figures, so please keep your appointment even if you have not completed this questionnaire.
Your Name ________________________________________ Today’s Date ______________
Address _____________________________________________________________________
Daytime Phone___________________ Evening Phone ______________________________
Your Date of Birth ___________________ Your S.S. #: _____________________________
Your Heirs (Children, Parents, or Siblings):
1. ____________________________________________________________________________
First Name MI Last Name (C, P, or S) Age
____________________________________________________________________________
Residential Address State Zip Code Home Phone
2. ____________________________________________________________________________
First Name MI Last Name Age
____________________________________________________________________________
Residential Address State Zip Code Home Phone
Do you have any children by a previous relationship? Y N
Do you have children who died leaving children? Y N
Do you or your children have any adopted or illegitimate children? Y N
Is there someone you would want to exclude from receiving an inheritance? Y N
Does anyone to whom you may be leaving part of your estate require any help
or protection in managing money or other property? Y N
Is anyone in your household disabled? Y N
Are you or any of your children currently receiving Social Security Disability
or Supplemental Security Income (SSI) benefits? Y N
Is anyone in your family currently in a nursing home or
receiving Medical Assistance (i.e., Medicaid) benefits? Y N
Are you a Veteran? Y N
Do you expect to receive an inheritance from someone? Y N
Do you have any financial obligations arising from the dissolution of a
marriage or support actions? Y N
(if so, please bring a copy of your separation agreement
with you to the meeting)
Are you currently serving as the executor or administrator
of an estate, or as a guardian or conservator? Y N
Are you currently involved in a lawsuit, or expect to be involved in one? Y N
Are you concerned about protecting your home and other assets from current
or future lawsuits against you and your children? Y N
Are you concerned about what would happen to your home and other assets
if you ever had to go into a nursing home? Y N
Do you currently have long term care insurance? Y N
Are you the beneficiary of a trust? (if so, please bring a copy of it with you
to the meeting) Y N
Do you own a home? (If so, please bring your deed or mobile
home title with you to the meeting, if you can find it.) Y N
Do you believe you have any defects in the title to your real estate? Y N
Do you have a mortgage? Y N
If yes, how much is currently owed? _______________________________
Have you ever transferred any ownership interest in any property to anyone? Y N
If you own a home, roughly how much is it worth? (The assessed value on your
real estate tax bill may give an indication of how much it is currently worth.) __________________
Do you own any real estate other than your home? Y N
If you own any real estate other than your home, roughly how much is it worth?
Are you a United States citizens? Y N
Do you have any income‑producing assets (i.e., bank accounts,
CDs, mutual funds, stocks or bonds)? Y N
If you have any income‑producing assets, approximately how much do you have?
Do any of your income‑producing assets have a name on the
account other than your name? Y N
Do you use a tax preparer? Y N
If so, who?
______________________________________________________________________________
Name Address
Do you have a financial advisor? Y N
If so, who?
______________________________________________________________________________
Name Address
Do you wish to make any gifts to charity in your will? Y N
Do you have any serious health problems? Y N
Do you have any large debts that concern you? Y N
Do you currently have any life insurance policies? Y N
If you have life insurance, approximately how much do you have and who is the beneficiary?
Primary beneficiary:
Secondary beneficiary:
Amount(s):
Do you have any IRAs, vested pension, profit sharing or other retirement plan
benefits, annuities or other assets that would pass on your death to
a particular beneficiary that you have designated? Y N
If you have any IRAs, vested pension, profit sharing or other retirement plan benefits, annuities or other assets that would pass on your death to a particular beneficiary, approximately how much do you have and who is the beneficiary?
Primary beneficiary:
Secondary beneficiary:
Amount(s):
If you were in a hospital and unable to make decisions for yourself, with whom would you want your doctor to consult about your care?
1.___________________________________________________________________________
Name Day Ph. Night Ph.
2.___________________________________________________________________________
Name Day Ph. Night Ph.
Who knows best how you wish to live your life and would attempt to help you if you ever became incapacitated?
1.___________________________________________________________________________
Name Day Ph. Night Ph.
2.___________________________________________________________________________
Name Day Ph. Night Ph.
If you were unable to carry out your financial business, who would you want to pay bills,
make investment decisions, and carry out other transactions for you?
1.___________________________________________________________________________
Name Day Ph. Night Ph.
2.___________________________________________________________________________
Name Day Ph. Night Ph.
If you have some specific issue you wish to address in our meeting, please describe it below.
_______________________________________________________________________________
_______________________________________________________________________________
Do you have an e-mail address? ____________________________________________________
If you were referred to this office, who may I thank? _________________________________
FEE AGREEMENT
I understand that:
The initial conference is billed at the rate of $200.00 per hour. At the end of the conference, I will be quoted a rough estimate of the total fee UPON MY REQUEST. Attorney Rudolf will interview me during this conference and recommend a course of action for me. I will be billed for the initial conference and her legal services in determining a recommended course of action, drafting and filing documents and phone calls.
The cost of Attorney Rudolf's recommended course of action after the initial conference may reflect (1) the time that she may spend based on her hourly rate; (2) the amount involved, results obtained and complexity of the matter; and (3) the time limitations imposed on her or by the circumstances.
Client Signature: Attorney Signature:
Signed: ___________________________ ________________________________
Dated: ____________________________ ________________________________