ESTATE PLANNING QUESTIONNAIRE - Wild Apricot



IMPORTANT INFORMATION

Date:

GENERAL INFORMATION

Birth Name:

Other Names Used:

Current Legal Name:

Mother’s Maiden Name (birth date and place; address and telephone, if still living):

Father’s Name (birth date and place; address and telephone, if still living):

Birth - Date: County:

State: City:

Race (White, Black, American Indian, Asian, Hispanic, Cuban, Mexican, etc):

Social Security Number: Citizenship:

Passport Number: Cedula Number:

Home Address:

Other Residences:

Telephone: Email: Cell: Whatsapp:

Best way to reach you:

Primary Physician:

Address: Telephone:

Marital Status (legal): Single Married Divorced Separated Widow(er) Common Law

Full Name: When and where did marriage occur:

Emergency Contacts:

Name: Telephone: Email: Cell: Whatsapp:

Attorney – Ecuadorian

Attorney – Home Country

Power of Attorney/Executor – Ecuador

Power of Attorney/Executor – Home Country

HISTORY

EDUCATION:

Highest level of education: Degrees:

OCCUPATION/USUAL PROFESSION:

Employer (If still employed):

Business Address: Position:

MILITARY RECORD:

Branch of service:

Entrance date: Serial Number:

Discharge date: Discharge type:

Highest rank:

Wars/conflicts:

Medals & decorations:

SPOUSE (if applicable) GENERAL INFORMATION:

Birth Name:

Other Names Used:

Current Legal Name:

Mother’s Maiden Name (address, telephone and birth date if still living):

Father’s Name (address, telephone and birth date if still living):

Birth - Date: County:

Race (White, Black, American Indian, Asian, Hispanic (Cuban, Mexican, etc):

Social Security Number: Citizenship:

Passport Number: Cedula Number:

CHILDREN

Birth Name:

Other names used:

Current legal name:

Birth - Date: County:

City: State/Zip:

Social Security Number: Citizenship:

Passport Number: Cedula Number:

Home Address:

Other Residences:

Telephone: Email: Cell: Whatsapp:

Relationship to you:

Blood Relation? Related to you only? Spouse only? Both?

Number of Grandchildren?

Number of Great Grandchildren?

ELECTRONIC INFORMATION

Website Login Password Recovery email or phone

On line data storage

Facebook

Cell phone

Whatsapp

Personal/business website

PayPal

Financial Institutions

Paid Subscriptions

Others

FINANCIAL INFORMATION

ASSETS

(Note: Indicate if owned by you, your spouse or jointly.)

Location Account Number Ownership Value

Cash

Bank Accounts

Money Market Funds

Certificates of Deposit

Bonds and Bond Funds

Bit Coin

Listed Stocks and Mutual Funds

Listed Partnerships

Residence

Second Home(s)

Investment Real Estate

Professions or Business in which you are active (Sole Proprietorship,

Partnerships or Corporations)

Closely Held Business (in which you are not active)

Life Insurance

Annuities

Interests in Estates or Trusts

Home Furnishings

Automobiles

Collections

Other Personal Effects

Other:

RETIREMENT PLANS

(IRA, Keogh, Pension or Profit Sharing)

Participant: Type:

Beneficiary:

Present Value $

TOTAL ASSETS: $

LIABILITIES

Location Account Number Ownership Debt Amount

Creditors:

Credit cards

Medical

Other

Assets Encumbered:

Mortgage

Auto loan

Other

Other Personal Liability:

Personal Loan

TOTAL LIABILITY: $

LESS ASSETS: $

NET WORTH: $

MONTHLY BILL PAYMENTS

Company Location Account Number Amount

Bills paid in cash:

Bills paid electronically:

ADDITIONAL FINANCIAL INFORMATION

1. If you or your spouse were married previously, indicate to whom, when and how the marriage was terminated, whether there were children of such marriage and whether there are any continuing rights or obligations arising pursuant to any property settlement agreement or divorce decree.

2. In what states have you resided during your marriage?

3. Have you and your spouse entered into a pre-nuptial or post-nuptial agreement?

4. Has either spouse filed gift tax returns or made any gifts (outright or in trust) exceeding $11,000 per year to any person?

5. Does either spouse have a power of appointment or other interest under a will or trust created by someone else?

6. Does either spouse expect a significant inheritance?

7. Is either spouse a party to a buy-sell agreement, stock option plan, salary continuation plan or other deferred compensation plan other than a qualified pension or profit sharing plan?

8. To what degree is each spouse capable of managing financial affairs?

9. Does either spouse want to control the way his or her assets pass after the other spouse dies (as opposed to giving the other spouse such control)?

10. If a trust is established for the surviving spouse, to what extent should he or she be permitted to invade the principal?

11. Is there anyone other than your spouse and children for whom you are financially responsible or to whom you or your spouse wish to leave a part of your estate?

12. Is anyone (other than your spouse) dependent upon you for support? If so, please identify the person, and provide some general information as to the reason for, and extent of, support provided.

13. Do any potential beneficiaries of your estate have any physical or mental disabilities or extraordinary needs?

14. Is any of the property or income of you or your spouse the subject of a legal proceeding or ownership dispute, under a lien or court order, or is otherwise inaccessible or non-marketable?

15. During the last 36 months, have either you or your spouse made any large gifts ($500 or more in value), placed any property into trust, transferred any real estate or other property for less than fair market value, or removed or added names to joint accounts? If yes, we will need to know the date and the amount of each gift or transfer.

16. Does a child, parent, sibling, or other family member currently live in your home?

17. Are there recent nursing home expenses, medical expenses, or hospital bills of either spouse, that have not been paid and are not expected to be paid by Medicare, Medigap insurance, long-term care insurance, or other insurance?

18. Do you or your spouse have a safe deposit box? If so, where is each located, and in what name or names is each maintained?

19. Do you own real estate in another state or country?

ADVISORS

Name Address Telephone

Accountant:

Life Insurance Agent:

Investment Advisor:

Stockbroker:

Attorney:

Other Consultant or Advisor:

(If spouse uses different advisors, please note and provide the same information for spouse's advisors.)

POWER OF ATTORNEY

(Powers of Attorney are only valid while you are alive. Your Executor takes over after your death.)

Do you now have a Power of Attorney?

If so, who is the named power of attorney?

If no Power of Attorney

Who would you like named as General (business) Power of Attorney? (Someone you trust completely, good with bookkeeping)

Who would you like named as Alternate General (business) Power of Attorney?

MONITORING

You need to decide whether you want any of your agent's actions monitored or reviewed by someone else. An advantage of a power of attorney is that it does not require court supervision. This lack of supervision also is one disadvantage of a power of attorney. You may want to add a provision requiring your agent to report to someone else if you become incapacitated and are not able to supervise what your agent is doing.

Do you want your agent to give an annual financial report to another family member or friend?

PAYING FEES

Decide whether you want to pay your agent for the time spent carrying out your decisions. An agent always can be reimbursed for expenses paid out-of-pocket on your behalf. In addition, you can authorize your agent to take an hourly fee. Professionals, like banks or accountants, normally charge a fee, but this is usually not done if the agent is a family member. If you want to authorize a fee, you need to require your agent to keep time records and charge a reasonable hourly rate. If the agent takes the fee, it is taxable income. You can specify a rate, if you wish.

Do you want your agent to be paid? Yes ____ No ____

If yes, how much? ____ "Reasonable amount" or ____ "hourly rate of $ _____ "

1

2

3 TRUST INFORMATION

(Note: Trusts are not commonly used in Ecuador)

Do you currently have a Trust? Date of Trust::

Prepared by: State:

Successor Trustee:

Address:

Telephone:

1 If no Trust

Who would you like to be Trustee? (Yourself, you and your spouse, other)

Who would you like to be Successor Trustee?

1st Choice

Name:

Address:

Telephone:

Relationship:

WILL INFORMATION

Do you have a Will? Date of Will:

Prepared by:

Personal Representative (Executor):

Address: Telephone:

If no Will:

Name: Address: Telephone: Relationship:

Who would you like named as Personal Representative (Executor) of your Will? (Someone you trust completely, good with bookkeeping and details)

Who would you like named as Alternative Executor of your Will?

Who would you like to be guardian of your minor children?

Beneficiaries:

(Keep in mind that Ecuadorian law is 50% to living spouse and 50% divided among living, blood children. If you indicate otherwise, your Will will be honored unless any blood children contest, in which case, the Ecuadorian law takes precedence.)

After your death, who would you like to receive your estate?

In general, how do you want your estate distributed among your beneficiaries?

(equally, percentages to each child, other)

Do you wish to have any restrictions to the distribution of the proceeds of your estate to your beneficiaries (age restrictions, incremental distribution)

Do you want to make a gift (cash or a specific item) to a charity, foundation, religious or fraternal organization? (name, address, description of gift)

Alternate Beneficiaries: Who should receive your estate if you (and your spouse) outlive the Beneficiaries you have named above?

Name any relative that you wish to disinherit from our estate.

SPECIAL BEQUEATHS:

Beneficiary Article

MEDICAL INFORMATION

Primary Physician:

Address: Telephone:

Spouse

Primary Physician:

Address: Telephone:

Do you have health care insurance? With whom?

Do you have long term health care insurance? With whom?

Have you had treatments for (cancer, tuberculosis, kidney disease, diabetes, circulatory problems, heart)?

Are you allergic to anything?

LIVING WILL/HEALTH CARE DIRECTIVE

(These documents and wishes may or may not be honored when the time comes in Ecuador, but at least your caregivers will have some guidelines.)

Do you currently have a Living Will?

Do you currently have a Health Care Power of Attorney?

If not

Who would you like named as your Health Care Power of Attorney? (Someone you trust completely, perhaps with medical knowledge and is willing to be a pro-active caregiver)

Who would you like named as your Alternate Health Care Power of Attorney?

If you are unable to speak for yourself and are deemed “terminal” (terminal condition/end stage condition/permanent vegetative state) by two physicians and your Health Care Power of Attorney agrees, what are your preferences?:

Do you want to be revived or resuscitated (CPR)?

Cardiopulmonary resuscitation: Cardiopulmonary resuscitation (CPR) is a group of treatments used when someone's heart and/or breathing stops. CPR is used in an attempt to restart the heart and breathing. It may consist only of mouth-to-mouth breathing or it can include pressing on the chest to mimic the heart's function and cause blood to circulate. Electric shock and drugs also are used frequently to stimulate the heart. When used quickly in response to a sudden event like a heart attack or drowning, CPR can be life saving. But the success rate is extremely low for people who are at the end of a terminal disease process. Critically ill patients who receive CPR have a small chance of recovering and leaving the hospital. If you do not wish to receive CPR under certain circumstances, and you are in the hospital, your doctor must write a separate do-not-resuscitate (DNR) order on the chart. If you are at home, some states allow for a non-hospital DNR order. This order is written by a physician and directs emergency workers not to start CPR.

Do you want mechanical respiration/ventilation?

Mechanical ventilation: Mechanical ventilation is used to support or replace the function of the lungs. A machine called a ventilator (or respirator) forces air into the lungs. The ventilator is attached to a tube inserted in the nose or mouth and down into the windpipe (or trachea). Mechanical ventilation often is used to assist a person through a short-term problem or for prolonged periods in which irreversible respiratory failure exists due to injuries to the upper spinal cord or a progressive neurological disease. Some people on long-term mechanical ventilation are able to enjoy themselves and live a quality of life that is important to them. For the dying patient, however, mechanical ventilation often merely prolongs the dying process until some other body system fails. It may supply oxygen, but it cannot improve the underlying condition. When discussing end-of-life wishes, make clear to loved ones and your physician whether you would want mechanical ventilation if you would never regain the ability to breathe on your own or return to a quality of life acceptable to you.

Do you want antibiotics?

Do you want kidney dialysis?

Do you want tube feeding or any other artificial or invasive form of nutrition (food)?

Do you want any artificial or invasive form of hydration (water)?

Artificial nutrition and hydration: artificial nutrition and hydration (or tube feeding) supplements or replaces ordinary eating and drinking by giving a chemically balanced mix of nutrients and fluids through a tube placed directly into the stomach, the upper intestine or a vein. Artificial nutrition and hydration can save lives when used until the body heals. Long-term artificial nutrition and hydration may be given to people with serious intestinal disorders that impair their ability to digest food, thereby helping them to enjoy a quality of life that is important to them. But long-term use of the tube feeding frequently is given to people with irreversible and end-stage conditions. Often, the treatment will not reverse the course of the disease itself or improve the quality of life. Some health care facilities and physicians may not agree with stopping or withdrawing tube feeding. Therefore, explore this issue with your loved ones and physician and clearly state your wishes about artificial nutrition and hydration in your advance directive.

Do you want blood or blood products?

Do you want any form of life sustaining surgery or invasive diagnostic tests?

Do you want to allow physicians to try new medical discoveries on you?

Do you wish to donate your body to medical science?

Do you wish to donate any organs or tissues?

If pregnant, do you wish the baby’s life to take priority?

If pregnant, do you wish your life to take priority?

I wish my Agent/Health Care Power of Attorney to have the authority to: Indicate YES or NO

To make contracts on my behalf for any health care related service or facility, and to hire and fire medical or other support personnel for my care, without the agent incurring personal financial liability for such arrangements.

To consent, refuse, or withdraw consent to any and all types of medical care, treatment, surgical and/or diagnostic procedures, medication, and the use of mechanical or other means to affect any bodily function, including (but not limited to) artificial respiration and cardiopulmonary resuscitation.

To authorize my admission to or discharge from any hospital, nursing home or other facility, even against medical advice.

To authorize any medication or procedure intended to relieve pain, even though such treatment might lead to bodily damage, drug addiction, or hasten the moment of (but not intentionally cause) my death.

I wish my agent to have the same access to medical records and information to which I am entitled.

At the time of my death, if possible, I prefer: Indicate YES or NO

To have minimal drugs in order to relieve any pain and allow the most consciousness.

To be pain-free is my priority.

To live my last days at home.

I want to be hospitalized.

I have no preference of location.

To have my body left undisturbed for 3 hours after my death is declared.

To have my body left undisturbed for 3 days after my death is declared.

Other:

BODY DISPOSAL ARRANGEMENTS

Have you made any pre-need arrangements? With whom? Details:

Do you have “Away From Home Protection” (Contingency insurance should you die someplace other than your home)? With whom?

How do you plan to pay for your body disposal?

Do you have Funeral Insurance?

Do you have a Funeral Totten (Burial) Trust Account?

Would you prefer to be buried or cremated?

IF BURIAL PREFERRED

(Average cost of traditional US funeral and burial - $8,000-$10,000)

Buried where? (state, city, cemetery)

Do you wish to be embalmed? (Not usually required – refrigeration accomplishes the same thing. Prehaps required if viewing/open casket requested)

Do you wish to have a viewing of your body?

Before or just prior to the service?

Private or public?

Any special request for burial clothing? (color, style)

What personal accessories would you like in your casket? (wedding band, eyeglasses, jewelry, rosary) Would you like them returned to someone/whom?

Do you wish to have an open or closed casket at your service?

How much would you like to be spent on your casket? (from about $200 for particle board up to $25,000, average about $3,000)

Do you wish to have a graveside service?

Do you prefer your body placed in a:

Family estate, companion or single grave site?

Mausoleum (building), lawn crypt (above ground), in ground burial?

What would you like your grave marker/monument to say? (not typically done in Ecuador)

2 What would you like your grave marker/monument to look like? (not typically done in Ecuador) (Flat markers are made of either bronze or granite, raised markers and monuments are made of granite. Monuments usually mark four or more graves. Some cemeteries have specific requirements.)

IF CREMATION PREFERRED:

(Less expensive and easier than burial, depends on other services requested. Bodies tend to get moved after 3-7 years.)

Do you wish your family to wait three days before cremation?

Do you wish to be embalmed (prehaps required if viewing requested)?

Do you wish to have a minimal casket/container for cremation or a more expensive one? (minimal one usually required, often included in fee) How much are you willing to spend?

Do you wish to have a viewing of your body before cremation? (If so, your family will have to pay extra. Private or public?)

Do you wish a casket to be rented, if available, for the viewing?

What would you prefer be done with your ashes? (entombed in memorial niche in columbarium, buried in cemetery, scattered in sea, garden, made into a reef, other)

How much would you like to spend on an urn? (little or nothing for a minimal container up, often included in fee) $

Type of cremation container (hardwood, metal, ceramic, special request. Some cemeteries have special requirements if urn burial is requested)?

Do you wish to have a graveside service to inure the urn?

Who is to take responsibility for your ashes?

FUNERAL/CELEBRATION/MEMORIAL

Would you like to have a “Living Celebration of Life”, which takes place before your actual death?

Do you wish to have a visitation for your family before your service?

Where (funeral home, church, home, hotel, other – body not necessarily present)

Do you have any preferences as to location of funeral/celebration service?

Do you want an open to all or family-only service?

If open, is there a list or address book? If so, where?

Do you have a preference as to who would conduct your funeral/celebration service?

Do you wish to have your ashes or casket at your funeral/celebration service?

Any preference of music, readings, poetry, etc. for your funeral/celebration service?

Do you have a religious affiliation? Where?

Any special religious rites or rituals requested?

Do you wish to have military funeral benefits, if eligible, in the US (flag folded or draped – handed to whom; gun salute, taps)?

Do you have a floral preference?

Do you wish to have charitable donations made rather than flowers at your funeral? If so, to what charity(ies)?

Would you like any of the following at your funeral/celebration service: balloons, white doves, candles, pictures (indicate which one[s]), personal or religious figures, angels?

Do you want a guest book at your celebration? To go to whom?

Do you wish to have memorial folders or prayer cards? Suggestions?

Do you wish to have a gathering after your funeral/celebration service? Where?

Have you written your obituary?

What newspapers would you like notices sent to?

WHOM WOULD YOU LIKE NOTIFIED UPON DEATH

(Name and phone number or location and description of address book with indication noted)

Family:

Close Friends:

Advisors:

Organizations:

Others:

DOCUMENT COPIES TO BE LOCATED IN ONE PLACE

Transition Planning Questionnaire

Existing wills or trusts of either spouse

Federal gift tax returns that either spouse may have filed.

Pre-nuptial, post-nuptial or marital settlement agreement that either spouse has signed.

Will or trust under which either spouse has an interest.

Net worth statements (assets and liabilities)

Complete list of all assets and liabilities (addresses, credit cards, numbers, etc)

Any buy-sell agreement, stock option plan, salary continuation plan or other deferred compensation plan to which either spouse is a party, including beneficiary designations.

Bank statements

Bank account information

Tax returns

Stock and Bond certificates

Brokerage statements

Life and health insurance policies

Annuity contracts

Disability income papers

Deeds and leases to property

Medicare/Medicaid information

Ownership and beneficiary designations for life insurance policies, and beneficiary designations for IRAs and qualified plans [pension, 401(k) & profit-sharing].

Safety deposit box information and key (location and authority)

Employment contracts

Partnership agreements

Buy/sell agreements

Transfer on Death Agreements

List of advisors

Powers of Attorney general or health care.

Health insurance information

List of physicians

List of medications

Birth Certificate

Military Papers

Marriage or divorce papers

Adoption papers

Deeds to home

Car, RV, mobile home titles and insurance policies

Any other legal documents

Burial/cremation/memorial instructions, deeds, prepaid plans

Your obituary and eulogy

“Away From Home Protection” policy

List of family members and friends to contact with phone numbers or location of such information

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