"CONFIDENTIAL WILL QUESTIONNAIRE"

  KENNETH VERCAMMEN & ASSOCIATES, PC

ATTORNEY AT LAW

2053 Woodbridge Ave

Edison, NJ  08817 

(Phone) 732-572-0500

(Fax) 732-572-0030

"CONFIDENTIAL WILL QUESTIONNAIRE" 

         Please fill out completely and fax or mail back. This form is extremely important. Your accuracy and completeness in responding will help me best represent you. All sections and information must be filled out prior to sitting down with the attorney.

         Please be sure to check all appropriate boxes. If "NONE", please state "NONE".  If "NOT APPLICABLE", please state "N/A"  

PLEASE PRINT CLEARLY 

1.   Your Full Name: _____________________________________________

2.    IF MARRIED OR SEPARATED, complete (a) and (b) below.  If married no need to fill out separate forms unless you want different Executors 

Spouse's Full Name: ___________________________________       _______              

                                   First                         Last 

3.  Your Street Address: ____________________________________       

City _______________________ State ____  Zip Code ______________

              

4.    Telephone Numbers:                 

Cell: _______________________________  other #  _____________________

                                                                                       

5.    E-mail address: _______________________________________

6. Referred By: ___________________________________________

         If referred by a person, is this a client or attorney?  If you heard about the law office on the Internet, what search terms did you use? If Legal plan, write Claim number. [Hyatt, UAW] _______

7. Today's Date ____________________

       We recommend a DurablePowerofAttorneyin the event of your physical 

or mental disability to help you with financial affairs?  

                                                                             Yes ________ No ________

    We recommend a Living Willtelling hospitals and doctors not to prolong your life by artificial means, i.e. Terri Schiavo; Karen Quinlan?       

                                                                          

                                                                           Yes ________ No ________

Confidential Will Q                        Rev 5/4/19

  How can we help you? What are your questions/other important information that need to be addressed?

_______________________________________________________________________

_______________________________________________________________________

[It is required by Court Rules that all pages be filled out in person's own handwriting prior to seeing the attorney]

8.    Your Marital Status:        [  ] Single        [  ] Married         [  ]  Separated                       [  ] Divorced        [  ]  Widowed  

9.  Your Day/Month  of birth: ___________________   

                                         

10.  Spouse Day/Month of birth:  _________________   

                                            

11.  If you are the parent or legal guardian of a minor child or minor children, please check here.  [   ] 

2. ESTATE EXECUTOR 

         The person charged with administering/Probating your estate, paying taxes and/or other debts, preserving, managing, and distributing estate assets and property is called an Executor. This person should be one in whom you have trust and confidence. Your SPOUSE is usually named as primary Executor, followed by the child who lives closest to your home. 

         Please provide the following information about the person you wish to name to serve in this capacity.

1.PRIMARY Choice of Executor/Personal Representative in Power of Attorney:

Name: _________________________     ______________________________

            First                                             Last

Relationship: _______________ Address: ________________________

2.SECOND Choice of Executor/Personal Representative in Power of Attorney:

         This individual will serve in the event that the primary executor/personal representative is not alive at the time of your death, or is unable to serve.

Name: _________________________     ______________________________

            First                                             Last

Relationship: _______________  Address: _____________________________

    The two proposed Executors must be filled out prior to meeting the attorney. We do not recommend Joint Executors, which often cause conflicts and additional work for the Estate. It is best to select one primary person, then a secondary person.

Asset Information- Must Be Completed-If none, write “none”

House/Real Estate Address  _________________________________________

Other Real Estate Address  _________________________________________

Estimate Total Real Estate Value:_____________ mortgagebalance _________

Bank Accounts, Stocks, CDs and Assets:_______________________________

Approximate Amount______________________________________________

Direct Beneficiaries of Accounts -If none write "none"____________________

Other Major Assets -If none, write "none"_____________________________

Approximate Life Insurance:_________________    Beneficiary_____________

  Is total more or less than $11,500,000 ? ____________ 

In the Will- Who do you want to get your assets:

Beneficiary (1) _______________________   Relationship_______________

Beneficiary (2) _______________________   Relationship_______________

Beneficiary (3)_______________________   Relationship_______________

    It is required that major assets and beneficiaries be filled out prior to seeing the attorney. A best guess. Also, list who receives assets if a beneficiary dies prior to you if that person’s share does not go to their children.

Any Specific Bequests of Money and Property:

______________________________________________________________

 [  ] A. MARRIED PERSONS WITH CHILD(REN) OR GRANDCHILD(REN).

       Generally most married people provide that, upon their death, property will be distributed as follows:

         1. Your estate (all property and assets not owned jointly with another person) will be distributed to your surviving spouse.

         2. If your spouse predeceases you, then your estate will be divided in equal shares among all of your living children, If any child shall predecease you, then that child's share to their children (grandchildren).

Names of Children:  ______________________________  Age: _____

____________________________________________    Age: _____

    LIST THE NAMES AND AGES OF ALL CHILDREN EVEN IF THEY ARE OLDER THAN EIGHTEEN. IF NO CHILDREN, WRITE NONE.If no minor children, skip page 5.

III. GUARDIAN(S) OF MINOR CHILD(REN) or Trustees of Trust

       [Skip this section if you have NO minor children and DO NOT want a trust. There are substantial additional fees for preparation of a Trust, minimum $2,500 for stand alone trusts]

       The surviving parent of a minor child is ordinarily entitled to be the GUARDIAN of that child. In the case of simultaneous death of you and your spouse, or if you are a single parent, you should appoint a Guardian for your minor child. It is advisable, prior to the completion of this Questionnaire, to make sure that your proposed Guardian(s) is (are) willing to serve as Guardian(s). In addition, the Guardian will also hold the monies for the minor children UNLESS you direct us otherwise. In your Will you can have any adult serve as Trustee of monies for minor children.

         Provide the following information about the person(s) you select to be Guardian(s)/Trustee(s). In the event my spouse predeceases me, I name as GUARDIAN(S)/ TRUSTEE(S):

1.  PRIMARYChoice of GUARDIAN / TRUSTEE:

Full Name: _______________________________________

Relationship: ______________________________________

2.   SECONDChoice of GUARDIAN / TRUSTEE:

Full Name: _______________________________________

Relationship: _____________________________________

[  ] B. MARRIED PERSONS WITH NO CHILD(REN) OR GRANDCHILD(REN).

       Generally most married people with no child(ren) or grandchild(ren) provide that upon their death their property will be distributed as follows:

1. Your estate (all property and assets not owned jointly with another person) will be distributed to your surviving spouse, but

2. If your spouse predeceases you, then your estate will be distributed to your living parent, or equally to your living parents.  

3. But should both of your parents predecease you, then your estate will distributed equally to your brothers and sisters or equally to the children of a predeceased brother or sister.

         Please check B above only if you wish your property distributed precisely and exactly as indicated in section B, 1 through 3, above.

  Additional information on Wills, Probate and Elder Law available at www.njlaws.com. This interview form online at http://www.njlaws.com/will_questionnaire.html

[ ] C. DIVORCED OR WIDOWED PERSONS WITH CHILD(REN) OR GRANDCHILD(REN). Generally, most divorced or widowed persons with child(ren) or grandchild(ren) provide that upon their death property will be distributed as follows:  1. Your estate (all property and assets not owned jointly with another person) will be distributed in equal shares to all of your living child(ren).

         2. But if one or more of your children predeceases you, that deceased child's share will be distributed to his or her child(ren), your grandchild(ren) in equal shares

          [  ] D. ALTERNATE PLAN OF DISTRIBUTION - You may list specific gifts to individuals and/or divide your estate among several individuals by listing percentages to each, making sure that the percentages total 100%. You may add additional sheets if necessary or use the back of this form. There are additional Will preparation fees if there are gifts, called specific bequests. 

      Are there any beneficiaries with special needs, or receiving SSI or SDD? Please answer in detail      ___________________________

    Are you or any of your Beneficiaries  are not United States citizens? _______

If not US citizen, extra taxes may apply. 

Do you have any religious wishes on burial? ___, Are you a USA Veteran or Elks member?_

       PLEASE WRITE DOWN ANY QUESTIONS YOU HAVE HERE or anything else important that we should be aware. Use back of this page for additional important information or type a list:

______________________________________________________________

______________________________________________________________

        If your assets exceed $5,000,000 and you desire estate planning to avoid or reduce your estate tax or require a Trust to protect a spouse or children, please advise Mr. Vercammen.  A Standard Will is not designed to address estate tax issues. We do not do Medicaid Nursing Home Planning. The law office building has four steps in the front so please advise us if you need  assistance.

                 WILLS:

T 1- Parents with minor children and trust for children                 ____________

T 2- Parents no spouse                                                               ____________

T 3- Unmarried                                                                            ____________

T 4- Parents without trust                                                           ____________

T 5- Spouse Trust Will $ for spouse to go in Trust ? [2^ndmarriage 

or protect assets from Medicaid                                                   _____

         PAYMENT WILL BE MADE BY:  (Please circle one)

Check, Credit Card (Visa, Mastercard, American Express) or Cash 

Checks are payable to Vercammen PC

         Payment is required for Will, Power of Attorney and other document preparation at the first consult and prior to any documents being drafted. Minimum fee for Last Will and Testament preparation is $300 each. We charge a $150.00 consultation fee, which is credited to the preparation of the Will or other document. This $150.00 fee is non-refundable even if the documents are not prepared. If there are any changes to a draft Will, Power of Attorney, or other document, there will be a minimum charge of $75.00 per revision. The Will needs to be signed within 21 days of initial consult or an additional fee of $100.00 will be charged. Due to complexity and need to re-title assets, Fees for stand alone Trusts are minimum $3,000.

This form was filled out by:  sign name _________________________