Quest Single Form

Quest Single

Who referred you to Peter L. Klenk, Esquire?(Required)

Your Name

AKA

Citizenship

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone: (Home)

Telephone: (Work)

Marital History

Parents’ Name/Ages

Name

Age

Children

Name

Address

Date of Birth

Spouse’s Name

Beneficiaries: If you didn’t have to worry about taxes or any rules, how would you want your estate divided at your death? (ex: all to spouse, then equally to children, etc.).

Selecting the People Who Will Carry Out Your Estate Plan

In general, spouses select each other as the first person to serve and then they agree on a backup.

Executor: Person who “executes” your plan.

First Choice

Second Choice

Guardian: Person responsible for minor children’s physical custody.

First Choice

Second Choice

Trustee: Person responsible for any part of your estate left in trust.

First Choice

Second Choice

Durable Power of Attorney: Your attorney-in-fact may act for you in your absence or inability.

First Choice

Second Choice

Living Will (Health Care Directive): Authorizes removal of life support.

First Choice

Second Choice

Financial Background

The requested information will allow us to calculate potential estate tax liability. Please be as accurate as possible, but figures do not need to be accurate to the penny. If calculations are necessary, show them on the back of this page. Please round to the nearest thousand.

IRAs, 401K, 403bs, etc.

Where (asset location)

Approximate Current Value

Checking + Savings Accounts

Where (asset location)

Approximate Current Value

Checking + Savings Accounts

Where (asset location)

Approximate Current Value

Business you own (Please list)

Home (Please list)

Other real estate (Please list)

Life insurance (Please list)

Furniture & furnishings (approx. value)

Vehicles (approx. value)

Collections

Anything else of value

Total Assets

Liabilities

Mortgage on home

Other mortgages

Loans

Other debts (credit cards, loans, etc.)

Total Liabilities

*TOTAL NET WORTH: Assets - Liabilities =

*(If you sold everything for cash, paid off your bills, this is the amount you would have left over)

Death Benefits

List all life insurance policies that you own, that you are a beneficiary of, or other plans that pay out at your death.

Death Benefits

Name of Policy or Plan

Death Benefit

Present Value

Beneficiary

Please provide the following information.

Accountant Email Address

Accountant Phone

Life Insurance Agent Email Address

Life Insurance Agent Phone

Investment Advisor Email Address

Investment Advisor Phone

Trust Officer Email Address

Trust Officer Phone

Commercial Banker Email Address

Commercial Banker Phone

Stockbroker Email Address

Stockbroker Phone

Casualty Insurance Agent Email Address

Casualty Insurance Agent Phone

Quest Single Form

Quest Single

Children

Selecting the People Who Will Carry Out Your Estate Plan

Financial Background

IRAs, 401K, 403bs, etc.

Checking + Savings Accounts

Checking + Savings Accounts

Liabilities

Death Benefits

Please provide the following information.

Pages

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