Confidential Succession Questionnaire
Referred by:_______________________________________________________
Appointment Time:______am pm: /Date of Form Completion ___________
(Office Use Only) Start Time:______________End Time:____________________
Please provide the following information, If you need more space, you may use another sheet. If you are not certain about an
answer, leave it blank and it will be discussed during the consultation.
Client Information:
Social Security Number: ______________________ Drivers License No.__________________ State___________
Address: ____________________________________________Apt. #_____________________________________
City: ___________________________________ Parish: ____________ State: __________ Zip: ________________
Home Phone: (______) ________________________ Work Phone: (____) _________________________________
E-Mail Address: ______________________@________._______Cell Phone: (______) _______________________
A. Family
1. Decedent's Name:____________________________________________________________________
Occupation:___________________________________________________________________________
Social Security Number:_______-______-_____________
Date of Death:_______________________
Place of Death:
Date of Birth:_________________________
If not a U.S. citizen, please state country of citizenship:
2. Surviving Spouse:___________________________________________________________________
Occupation:_________________________________________________________________________
Social Security Number:
________________-____________-______________
Date of Birth: _______________________________________________________________________
If not a U.S. citizen, please state country of citizenship:
_______________________________________
3. Addresses and Phone Numbers:
Home Address:
__________________________________
_______________________________________________
Home Phone:(_____)________-__________
Office Address:
__________________________________
Office Phone: (_____)________-_________
_______________________________________________
4. Executor/Administrator:
Name:________________________________________________________________________________
Address: _______________________________________
Telephone: (_____)________-_________
_______________________________________________
5. How long has deceased lived in Louisiana? _______________________________________________
6. Date of marriage: ____________________________________________________________________
Place of marriage:______________________________________________________________________
7. Prior Marriage(s):___________________________________Date______________Deceased/Divorce
Prior Marriage(s):_____________________________________ Date_______________Deceased/Divorce
Prior Marriage(s):_____________________________________ Date_______________Deceased/Divorce
1 -­‐THE LAW OFFICE OF CHRISTOPHER M. STAHL 8. Children (Include any predeceased children):
Birthdate
Marital Status
________________________ ______________
Address: _______________________________
_______________________________________
Contact Phone:__________________________
Relationship
Name
_____/_____/_______
_________________ _________________
Name of Spouse:___________________
Birthdate
Marital Status
________________________ ______________
Address: _______________________________
_______________________________________
Contact Phone:__________________________
Relationship
Name
_____/_____/_______
_________________ _________________
Name of Spouse:___________________
Birthdate
Marital Status
________________________ ______________
Address: _______________________________
_______________________________________
Contact Phone:__________________________
Relationship
Name
_____/_____/_______
_________________ _________________
Name of Spouse:___________________
Birthdate
Marital Status
________________________ ______________
Address: _______________________________
_______________________________________
Contact Phone:__________________________
_____/_____/_______
_________________ _________________
Name of Spouse:___________________
Name
Relationship
SSN:
SSN:
SSN:
SSN:
9. Parents: (Complete only if deceased had no children and include predeceased parents)
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
10. Brothers and Sisters: (Complete only if deceased had no children and include predeceased siblings)
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
B. Advisors & Relationships
Certified Public Accountant:_________________________________________________________________________
Investment Advisor (individual and
company):___________________________________________________________
Insurance Agent(s ) (Company):
_______________________________________________________________________
Primary Banking
Relationship:________________________________________________________________________
2 -­‐THE LAW OFFICE OF CHRISTOPHER M. STAHL Secondary Banking Relationship:
______________________________________________________________________
Real Estate Appraiser:_______________________________________________________________________________
C. Wills and Agreements in Effect
Yes: [
]
No: [
]
2.
Did the deceased have a will? If yes, please provide original.
Will Location:
______________________________________________________________
Are there any trusts in effect? Please provide copies.
Yes: [
]
No: [
]
3.
Are there any marriage contracts in effect? If yes, please provide copies.
Yes: [
]
No: [
]
Yes: [
]
No: [
]
Yes: [
]
No: [
]
Yes: [
]
No: [
]
1.
D. Gift Tax Returns
1.
2.
3.
Did the decedent file federal or state gift tax returns? If yes, please provide
copies.
Did the decedent make gifts in excess of $10,000 for which no gift tax returns
have been filed?
Are there any marriage contracts in effect? If yes, please provide copies.
E. Financial Information
Schedule A: Real Estate and Mineral Rights
BRIEF DESCRIPTION
FAIR MARKET
VALUE
Separate Community
1. HOME
2. OTHER REAL ESTATE IN LOUISIANA:
3. OTHER REAL ESTATE OUTSIDE LOUISIANA:
4. MINERAL RIGHTS/ IROYALTY INTERESTS:
TOTAL VALUE
Schedule B: Stocks and Bonds
Company
3 -­‐THE LAW OFFICE OF CHRISTOPHER M. STAHL Certificate No.
Shares
FAIR MARKET
VALUE
Separate
Community
TOTAL VALUE
Please include all dividend reinvestment accounts, stock options and warrants. Please also include all
broker accounts.
Schedule C-1
BANK ACCOUNTS, CERTIFICATES OF DEPOSIT, CASH, NOTES, RECEIVABLES
Payable on
Name of Banks or Financial Institutions
FAIR MARKET VALUE
Death to a
Separate
Community
Beneficiary
1. Name of Banks/Financial Institutions:
Address:
Type of Account & No.:
2. Name of Banks/Financial Institutions:
Address:
Type of Account & No.:
3. Name of Banks/Financial Institutions:
Address:
Type of Account & No.:
TOTAL VALUE
Schedule C-2
U.S SAVINGS BONDS/ U.S TREASURY OBLIGATIONS
Brief Desription:
-
4 -­‐THE LAW OFFICE OF CHRISTOPHER M. STAHL Payable on Death to a
Beneficiary or How
Denominated
FAIR MARKET VALUE
Separate
Community
Schedule D: Life Insurance Policies and Annuities.
List the issuing company. To identify type of contract, use “T” for term insurance, “CV” for insurance policies having a cash
value, “A” for annuities.
Insurance Company
Type
Owner
Beneficiary
Cash Value
Death Benefit
1. ________________________
Policy No._________________
2. ________________________
Policy No._________________
3. ________________________
Policy No._________________
4. ________________________
Policy No._________________
Schedule E: Miscellaneous Property
Description
Owner
Market Value
Debt
1. Auto:_______________________
Year:______ Make:_____________
VIN:_________________________
2.
Mortgage:____________________
Type:_________ Year:___________
3.
4.
5.
PERSONAL EFFECTS
Brief Description:
1.Tools/Firearms:
2. Antiques:
3. Jewelry:
4. Furniture:
5- Coin/Art. Collections;
6. Claims or Intangibles:
7. Escrows or Deposits;
8. Debts Due Estate: ,
9. Miscellaneous:
TOTAL
5 -­‐THE LAW OFFICE OF CHRISTOPHER M. STAHL FAIR MARKET VALUE
Separate
Community
PARTNERSHIPS OR LIMITED LIABILITY COMPANIES:
Brief Description
% of Ownership
FAIR MARKET VALUE
Separate
Community
INTEREST IN THE FOLLOWING:
Deferred Contributions Plans:
Thrift Plan/ Profit Sharing Plan/ ESOP or
Stock Bonds
Participants
Beneficiary
Fair Market
Value
Participants
Beneficiary
Projected Annual
Payments
Owner
Beneficiary
Fair Market
Value
Owner
Beneficiary
Fair Market
Value
TOTAL
Defined Benefit Plans:
Company
TOTAL
IBA Accounts:
Bank or Institution
TOTAL
Annutities:
Bank or Institution
TOTAL
Other:
Name
Unpaid Salary
Rents Receivable
Notes Receivable
6 -­‐THE LAW OFFICE OF CHRISTOPHER M. STAHL Fair Market
Value
TOTAL
SCHEDULE F: Mortgages and Liens
AMOUNT OWED
Seperate
A. Mortgages on Home, Auto, or other property
1. Name of Institution :
2. Name of Institution:
3. Name of Institution:
Brief Description of Mortageg or Debt
B.Signature Loans at Bank or Other Insititutions
1. Name of Institution:
2. Name of Institution:
3. Name of Institution:
C. Current Debts (Utilities,etc.)
D.Medical and Other Expenses of Last Illness:
E. Funeral Expenses:
F. Other Debts
G. Usufructuary Accounting Due:
TOTAL
7 -­‐THE LAW OFFICE OF CHRISTOPHER M. STAHL Community
For Attorney Use Only:
1.
Date of Death:___________________________________
2.
Will
3.
Administration
4.
Death Certificate requested
5.
Federal Return Date
6.
LA Inheritance Tax Return
7.
Extension requested on LA return?
8.
Law Office of CMStahl responsible for stock transfer?
9.
Fee Agreement:
10.
Succession Access Affidavit Executed
Yes
____
Yes
____
Yes
____
Yes
____
Yes
____
Yes
____
Yes
____
Yes
____
Yes
____
No____
No____
No____
No.______________________
No____
When? : _________________
No____
When? : _________________
No____
No____
No____
Quoted:$________________
No____
When? : _________________
NOTES:
__________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 8 -­‐THE LAW OFFICE OF CHRISTOPHER M. STAHL