Attorney Mary Markovich
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Client Questionnaire

Name *
Date of Birth
Email *
Address
Day Phone *
Evening Phone *
County of Residence
U.S. Citizen Yes No
If no, citizen of
Employer
Retirement Date
Veteran Yes No
Spouse
Spouse's Date of Birth
U.S. Citizen Yes No
If no, citizen of
Employer
Retirement Date
Veteran Yes No
Veteran Yes No
Date of Marriage
Number of Children
Number of Grandchildren
   
Have you or your spouse been married before ? Yes No
If yes, do you or your spouse have any children from this previous marriage? Yes No
Do you or your spouse have children who have died leaving children? Yes No
Does anyone to whom you may be leaving part of your estate require any help or protection in managing money or other property?
Yes No
Do you and your spouse have a pre-nuptial or post-nuptial agreement? Yes No
MEDICAL/DISABILITY
Is anyone in your family disabled? Yes No
If yes, please explain
Is anyone at risk for becoming seriously ill or disabled because of a medical condition or family history? Yes No
If yes, please explain
Your Doctor
Spouse's Doctor
Has anyone in your family recently entered a hospital or skilled nursing facility? Yes No
Name of facility
Date of admission
Date of discharge
Diagnosis
HEALTH INSURANCE
Your Medicare Number
Spouse's Medicare Number
Insurance from Employer
Medicare Supplement
Long-Term Care Insurance
Other
INVESTMENTS AND SAVINGS
TOTAL
Have you or your spouse made any transfers or gifts during the past five years? Yes No
REAL ESTATE
Date Purchase Price Fair Market Value In Whose Name
Are any of the above properties not connected to a sewer line? Yes No
Do you or your spouse have an interest in any business? Yes No
MONTHLY INCOME
  You Your Spouse Joint
Monthly Income
Social Security
Employment
Pension from
IRAs, Annuities, etc.
Rents
Business Interest
Other
TOTALS
Which sources of income have a benefit for a surviving spouse?
LIFE INSURANCE
Whose Life Company Face Value Cash Value Policy Number Beneficiary
RETIREMENT ASSETS
Do you have IRAs, Vested Pension Plan, Annuities or Other Assets that would pass on your death to a particular designated beneficiary?   Yes No
Description Value Beneficiary
Do you or your spouse expect an inheritance? Yes No
Are you or your spouse the beneficiary of any trust? Yes No
LIABILITIES (mortgages, notes to banks, notes to others, loans on insurance, other)
Description Balance Due Monthly Payment Maturity Date
Location of important papers:
PERSONAL PROPERTY (Autos, R.V.s, Boats, Antiques, Heirlooms, Jewelry, Collections, etc.)
Description Value In Whose Name
LEGAL  
 
Date Made Location of Original
Last Will and Testament
Durable Power of Attorney
Living Will/Health Care Proxy
Living Trust
I am the legally appointed guardian of
I am serving as a power of attorney for
I am serving as executor or administrator of an estate Yes No
I am involved in a lawsuit Yes No
I have lived in a community property state (Arizona, Calif., Idaho, Louisiana, Nevada, New Mexico, Texas, Washington) Yes No
Other legal concerns

If possible, please bring copies of the following documents with you to your meeting with the attorney: 

1. Will, Codicil, Trust Agreements

2. Real Estate Deeds, Appraisals

3. Admission Agreements to hospitals and health facilities

4. Divorce Decrees, Prenuptial Agreements, Adoption Papers

5. Guardianship documents

6. Living Will, Health Care Declaration or Power of Attorney, Durable Powers of Attorney

7. A list of full names, addresses, telephone numbers of people who have a part in your planning as executors, trustees, beneficiaries of your estate, helpers, and advisors

8. Retirement plans, including any forms designating beneficiaries