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Information Needed to Form an Estate Plan


You may either fill out the form below and submit it via the internet to us, or you can print the same form and mail it to us at 447 Boston Street, Topsfield, MA 01923. To view the printer-friendly version of this questionnaire, please click here.

Personal and Contact Information

Full Name:


Other Names Used:


Email Address:


Home Address:


Occupation and Business Address:


Date of Birth:


Marital Status and Name and Age of Spouse:
If you selected "Married":

Names and Ages of all children (and addresses if living apart from you):


Names, Ages, and Addresses of all other Beneficiaries (for example: include parents, grandchildren, spouses of children, relatives or others you might desire to benefit):


Are you a beneficiary of any trust?


Do you anticipate relieving a substantial inheritance?
Estimated amount of inheritance: $

Financial Information

Provide your best estimates of the fair market value of the following categories of assets and liabilities:
Residence:
$

Other property owned:
(include addresses of each additional parcel of property)
$

Bank Accounts, Certificates of Deposit, Money market Funds, etc.:
$

Stocks, Bonds and Mutual Funds:
$

Subchapter S and other Closely Held Stock and Partnership Interests:
$

Retirement Benefits:
$

Insurance Policies (Death Benefits and any Cash Value):
$

Other assets:
$

List all liabilities:

Estate Planning Provisions

Please consider who you would like to administer your estate and care for your minor children:
Personal Representative (Primary and Secondary):
Provide names and addresses



Guardians (Primary and Secondary):
Provide names and addresses

Disposition of your Estate

Describe your general desires as to the disposition of your estate, indicating any specific gift(s) that you wish to make:


Also list any previous gift(s) that you have made in excess of $10.000, and that were not to a charity:

Power of Attorney

If you choose to have a Power of Attorney, please consider who you would like to designate to act on your behalf in the event that you become unable:
Names and addresses of both Primary and Successor:



Have you ever given a Power of Attorney to another?
If you selected "Yes", to whom and when?

Is it still in effect?

Health Care Proxy

If you choose to have a Health Care Proxy, please consider who you would like to designate to make health decisions on your behalf in the event that you are determined by a physician to be incompetent to make such decisions:
Names and addresses of both Primary and Successor:

Living Will

Do you wish to have a Living Will?

Documentation:

You should bring the following documentation with you at the time of the meeting if it is available:
  • Copies of all prior wills
  • Trust agreements
  • Powers of attorney
  • Health care proxies
  • Living wills
  • Life insurance policies
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