Estate Planning Questionnaire

Please fill out this form to the best of your abilities. This will aid us in preparing your estate planning.

Full Legal Name

First Name

Last Name

Spouse's Legal Name

First Name

Last Name

Email Address

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Mobile Phone

(###)

###

####

Other Real Estate

Advisors

Accountant

Name + Phone

Investment Advisor

Name + Phone

Children

Child #1

Child of:

Child's Name

First Name

Last Name

Child's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Phone

(###)

###

####

Child #2

Child of:

Child's Name

First Name

Last Name

Child's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Phone

(###)

###

####

Husband

In the event you are unable to handle your affairs with respect to your property, bank accounts, etc., who would you like to appoint as your attorney-in-fact if your SPOUSE is unable to act? Your attorney-in-fact is authorized to continue to act while you are incapacitated.

Name

First Name

Last Name

Relationship

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Husband

In the event you are unable to make medical decisions for yourself, who would you like to appoint as your health care surrogate if your SPOUSE is unable to act?

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Relationship

Phone

(###)

###

####

Wife

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Relationship

Wife

In the event you are unable to make medical decisions for yourself, who would you like to appoint as your health care surrogate if your SPOUSE is unable to act?

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Relationship

Administration

Who will administer your estate upon your death if your SPOUSE is unable to act?

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Relationship

Alternate

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Relationship

Miscellaneous notes regarding your affairs, please feel free to provide us with any additional information you would like us to consider in your planning:

Estate Planning Questionnaire

The

Karniewicz

Law Group

(813) 962-0747 • 1211 W Fletcher Ave • Tampa, FL 33612