Alta Estate Services - Estate Questionaire

CONFIDENTIAL ESTATE QUESTIONNAIRE

The following Confidential Estate Planning Questionnaire was created by ALTA Financial Services to further assist you in your financial and estate planning needs.

This document, when completed by you, will serve as an invaluable information resource for your family members and significant persons during times of need.

We strongly recommend that you take advantage of the benefits afforded by this opportunity. You will never fully realize the importance and value this program will provide to your family members and significant others during such times of need.

Please complete this Confidential Estate Questionnaire and submit the data to our office in order that we may maintain this information on your behalf. We will then be able to assist your family members and significant others to protect your estate assets and preserve your estate planning desires. If you prefer, please e-mail your name and address and we will be happy to send you a copy of the Confidential Estate questionnaire for you to complete. But remember to advise your family members and significant others of the existence and location of this document.

In addition, please feel free to call our office to obtain additional valuable information and benefits of this program as well as our 24 HOUR EMERGENCY HOTLINE TELEPHONE PROGRAM.

Go To a Specific Page by Clicking on Number Below:

1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16

Page 1 - Personal Information

Name:
Date of Birth:
Address:
City:
State:		Zip:
Telephone #:
Social Security #:
Marital Status:

Spouse's Name:
Address:
City:
State:		Zip:
Telephone #:
Social Security #:

Personal Physician:
Address:
City:
State:		Zip:
Telephone #:

Page 2 - Professional Services

Accountant:
Address:
Telephone:

Insurance Agent:
Address:
Telephone:

Attorney:
Address:
Telephone:

Stock Broker:
Address:
Telephone:

Page 3 - Banking Information

Banking Institution:
Address:
Telephone:
Bank Representative:
Checking Account#:
Savings Account#:

Banking Institution:
Address:
Telephone:
Bank Representative:
Checking Account#:
Savings Account#:

Banking Institution:
Address:
Telephone:
Bank Representative:
Checking Account#:
Savings Account#:

Page 4 - Banking Information - Cont.

Safe Deposit Box #1
Location:
Address:
Telephone:
Identification#:
Location of Keys:

Safe Deposit Box #2
Location:
Address:
Telephone:
Identification#:
Location of Keys:

Page 5 - Other Locations of Documents

Description:
Location:
Address:
Telephone:

Description:
Location:
Address:
Telephone:

Description:
Location:
Address:
Telephone:

Description:
Location:
Address:
Telephone:

Page 6 - Investments

Name of Company:
Address:
Telephone:
Account #:
Approx. Value:

Name of Company:
Address:
Telephone:
Account #:
Approx. Value:

Name of Company:
Address:
Telephone:
Account #:
Approx. Value:

Page 7 - IRA's, Pension Plans, Annuities, etc.

Name of Company:
Address:
Telephone:
Account #:
Approx. Value:

Name of Company:
Address:
Telephone:
Account #:
Approx. Value:

Name of Company:
Address:
Telephone:
Account #:
Approx. Value:

Page 8 & 9 - Life Insurance

Name of Company:
Address:
Telephone:
Policy #:
Policy Dollar Amount:
Location of Policy:

Name of Company:
Address:
Telephone:
Policy #:
Policy Dollar Amount:
Location of Policy:

Name of Company:
Address:
Telephone:
Policy #:
Policy Dollar Amount:
Location of Policy:

Name of Company:
Address:
Telephone:
Policy #:
Policy Dollar Amount:
Location of Policy:

Page 10 - Personal Property

List the following items in the box below:
(e.q. automobiles, motor homes, boats, collections, jewelry, personal possessions, etc.)

Provide Copies of all Deeds, Titles, Etc.
Description:
Location:
Interest Held:

Provide Copies of all Deeds, Titles, Etc.
Description:
Location:
Interest Held:

Provide Copies of all Deeds, Titles, Etc.
Description:
Location:
Interest Held:

Provide Copies of all Deeds, Titles, Etc.
Description:
Location:
Interest Held:

Page 11 - Business Interests

Name of Business:
Address:
Telephone:
	Ownership Management

Other Related Parties
Name:
Address:
Telephone:
Are there outstanding controlling agreements?
Please Describe:

Page 12 - Significant Persons

Name:
Address:
Telephone:

Name:
Address:
Telephone:

Name:
Address:
Telephone:

Name:
Address:
Telephone:

Page 13 - Next Closest Relatives or other Significant Persons

Name:
Address:
Telephone:

Name:
Address:
Telephone:

Name:
Address:
Telephone:

Name:
Address:
Telephone:

Page 14 - Estate Administration

IF YOU ARE UNABLE TO ACT FOR ANY REASON WHATSOEVER (i.e. incapacity, disability, or death), WHO DO YOU DESIRE TO ACT ON YOUR BEHALF?

FIRST CHOICE:
Name:
Address:
Telephone:

SECOND CHOICE:
Name:
Address:
Telephone:

THIRD CHOICE:
Name:
Address:
Telephone:

Page 15 - Burial Arrangements(if any)

Name of Cemetery:
Address:
Contact Person:
Telephone:
Preference:	BurialCremation

Page 16 - Additional Information