LGBQT QUESTIONAIRE

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CHILDREN OF THIS RELATIONSHIP

None

Enter details of children of this relationship

Number of grandchildren

Range of Ages

Click Yes or No for the following questions

	Yes	No
	Yes	No
Treat all children as if they were the children of both parties?
Any deceased children?
If yes, survived by issue?
Any adopted children?
Do any of your beneficiaries have a learning disability, special educational, medical or physical needs?
Do you have any relatives (other than children) who depend on you for all or part of their support?
Do you think any of your beneficiaries have special problems with spouses, drugs, alcohol or handling money?
Do you wish to disinherit any of your children, grandchildren or any other close relative?
Do you have an existing Property Agreement?
Do either of you expect to inherit substantial assets ($100,000 +)?
Do you have existing Wills?
Do you have any existing trusts?
Have you ever filed a Federal Gift Tax Return?
Should the surviving party have the power to control the distribution of the entire estate after the first death?
Do you want any assets to pass to any beneficiary before the second party's death?
If a beneficiary dies prior to the second party’s death, do you want the assets to go to that beneficiary’s issue?
Do you want assets passing to your beneficiaries to be held in trust until a specific age or ages?

Do you have existing Wills?*

Yes

Do you have any existing trusts?*

Yes

Name of Trust*

Date trust signed*

Select Date×

SUCCESSOR TRUSTEE: The name of the person(s) you want to be decision maker in the event of your disability or death. You can put the other party or any 4 names. that you want tobe the decision maker concerning your estate upon your death

Please list 4 names

SUCCESSOR GUARDIAN The name of the person(s) that you want to raise a child that is under 18, if both parties die (if applicable)

Please list 4 names

AGENT FOR MAJOR MEDICAL CARE The name of the person(s) other than the surviving party that you want tomake any major medical decisions on your behalf

Please list 4 names

In general, state how you want your estate distributed among your beneficiaries after the death of both of you?*

equally to my/our children or their issue

other explain IN DETAIL WHO GETS WHAT $ OR %.:

other explain IN DETAIL WHO GETS WHAT $ OR %.

State any specific concerns (not already mentioned) that you have regarding the distribution of your estate:

***Please also complete the supplemental form here

PARTY #1

(a) Choice Not to Prolong Life I do not want my life to be prolonged if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits,

Signature

(b) Choice to Prolong Life I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.

Signature

Click Yes or No for the following questions

	Yes	No
	Yes	No
Should your health care agent have the authority to make a disposition of a part or parts of your body (i.e., make any anatomical gifts)?
Should your agent have the authority to authorize an autopsy even if an autopsy is not required by law?
Do you wish to designate a primary physician?

PARTY #2

Signature

(b) Choice to Prolong Life I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.

Signature

Click Yes or No for the following questions

	Yes	No
	Yes	No
Should your health care agent have the authority to make a disposition of a part or parts of your body (i.e., make any anatomical gifts)?
Should your agent have the authority to authorize an autopsy even if an autopsy is not required by law?
Do you wish to designate a primary physician?

***Please also complete the supplemental form here

PARTY #1

At my death, I wish to be

Cremated

Buried

If cremation, I would like my ashes disposed as follows:

If buried, I would like my remains interred as follows:

I have already made arrangements at:

PARTY #2

At my death, I wish to be

Cremated

Buried

If cremation, I would like my ashes disposed as follows:

If buried, I would like my remains interred as follows:

I have already made arrangements at:

***Please also complete the supplemental form here

	PARTY #1'S SEP. PROP. ($)	PARTY #2'S SEP. PROP. ($)	JOINT PROPERTY ($)
	PARTY #1'S SEP. PROP. ($)	PARTY #2'S SEP. PROP. ($)	JOINT PROPERTY ($)
REAL ESTATE (fair market value, less loans)	PARTY #1'S SEP. PROP. ($)	PARTY #2'S SEP. PROP. ($)	JOINT PROPERTY ($)
SECURITIES (stocks, bonds, mutual funds)	PARTY #1'S SEP. PROP. ($)	PARTY #2'S SEP. PROP. ($)	JOINT PROPERTY ($)
CASH TYPE ASSETS (cash, annuities, notes due you)	PARTY #1'S SEP. PROP. ($)	PARTY #2'S SEP. PROP. ($)	JOINT PROPERTY ($)
BUSINESS INTERESTS (sole proprietorship, partnerships, closely held corporation, etc.)	PARTY #1'S SEP. PROP. ($)	PARTY #2'S SEP. PROP. ($)	JOINT PROPERTY ($)
RETIREMENT PLANS (IRA, 401k, etc. †)	PARTY #1'S SEP. PROP. ($)	PARTY #2'S SEP. PROP. ($)	JOINT PROPERTY ($)
VEHICLES (autos, R.V., boat)	PARTY #1'S SEP. PROP. ($)	PARTY #2'S SEP. PROP. ($)	JOINT PROPERTY ($)
PERSONAL PROPERTY (jewelry, furniture, antiques)	PARTY #1'S SEP. PROP. ($)	PARTY #2'S SEP. PROP. ($)	JOINT PROPERTY ($)
TOTAL	PARTY #1'S SEP. PROP. ($)	PARTY #2'S SEP. PROP. ($)	JOINT PROPERTY ($)

* Use best guess; this can be a “ballpark” estimate.

† Do not show benefits which will terminate at death (e.g., pension, social security, etc.). Value of Life Insurance policies will be listed separately on the next page.

***Please also complete the supplemental form here

• “Owner” will be “#1” or “#2” or “J”, if jointly owned;
• “Cash Value” use best estimate (term policies normally have no cash value)
• “Face Value” is the amount payable at death
• “Beneficiary” will be “#1”; “#2” wife; “C” child, “O” other

Feedback Matrix Title

	INSURED (#1 or #2)	OWNER (#1/#2/J)	CASH VALUE ($ estimate)	FACE VALUE ($ paid on death)	BENEFICIARY (#1/#2/C/O)
	INSURED (#1 or #2)	OWNER (#1/#2/J)	CASH VALUE ($ estimate)	FACE VALUE ($ paid on death)	BENEFICIARY (#1/#2/C/O)
1	INSURED (#1 or #2)	OWNER (#1/#2/J)	CASH VALUE ($ estimate)	FACE VALUE ($ paid on death)	BENEFICIARY (#1/#2/C/O)
2	INSURED (#1 or #2)	OWNER (#1/#2/J)	CASH VALUE ($ estimate)	FACE VALUE ($ paid on death)	BENEFICIARY (#1/#2/C/O)
3	INSURED (#1 or #2)	OWNER (#1/#2/J)	CASH VALUE ($ estimate)	FACE VALUE ($ paid on death)	BENEFICIARY (#1/#2/C/O)
4	INSURED (#1 or #2)	OWNER (#1/#2/J)	CASH VALUE ($ estimate)	FACE VALUE ($ paid on death)	BENEFICIARY (#1/#2/C/O)
5	INSURED (#1 or #2)	OWNER (#1/#2/J)	CASH VALUE ($ estimate)	FACE VALUE ($ paid on death)	BENEFICIARY (#1/#2/C/O)

WAIVER OF POTENTIAL CONFLICT OF INTEREST

WAIVER OF POTENTIAL CONFLICT OF INTEREST *

We have each read the foregoing material and understand that there are potential conflicts of interest between ourselves in the matters about which we are consulting you. If either of us desire to have separate counsel or desire you not to be involved at all, that party shall notify you. We each hereby consent to having you represent both of us in the drafting of our estate planning documents and we each hereby waive any potential or actual conflicts of interest. We understand that since you will be representing both of us on the same matter, as between ourselves and you, there are no confidential communications. NOTICE “Setting Every Community Up for Retirement Enhancement Act of 2019” (or “SECURE Act”)went into effect January 1st, 2020 affecting IRA and 401k, we do not provide TAX advice and we do not advise on the SECURE act contact your CPA for advice on these issues. Proposition 19 goes into effect on February 16, 2021 for any transfer of real estate between parent and child in the State of California. We do not give TAX advice and do not give advise on the PROP 19, contact your CPA for advice on these issues.

Dated×

Party #1’s Signature

Party #2’s Signature

***Please also complete the supplemental form here

Peter Robert Stone*
*Also Admitted Colorado

Peter Robert Stone

Attorney & Counselor At Law
A Professional Corporation

P.O. Box 41199
Sacramento, CA 95841
Telephone: 916-348-5600

AGREEMENT FOR

ELECTRONIC MESSAGING

AND STORAGE

I agree*

Client hereby agrees that Attorney shall use electronic mail, cell phone, text messaging, instant messaging, skype or other service, and electronic storage of their files and information. That all communications are agreed to be made in electronic form. By such communication, neither the client nor the attorney waives the attorney-client privilege. Files may be stored electronically in the cloud, the internet, or in the servers owned by law firm. Client understands that there is some risk in allowing the files to be stored and communications to be made electronically. However, there is also risk with physical storage; someone can just walk in and walk out with the file or letters. Client agrees that attorney shall not be liable for anyone hacking client’s email account or attorney’s email account, and that said hacking shall not waive the attorney-client privilege or other privilege. Client agrees that attorney shall not be liable for anyone hacking into the file storage devices. Client agrees to accept any communication electronically to the below addresses as though sent in person or by United States Mail. Client(s) understand all files are destroyed upon the signing of the estate planning documents, and only those documents are maintained permanently.

Client’s preferred email

Client’s secondary email

Client’s preferred text messaging

Client’s instant message

DATED×

Client Signature

***Please also complete the supplemental form here

LGBQT QUESTIONAIRE

Form successfully restored

Details of Party #1

Details of Party #2

Prior Marriages?

Enter details of children of this relationship

Children from prior relationship

PARTY #1

Signature

Signature

PARTY #2

Signature

Signature

PARTY #1

PARTY #2

WAIVER OF POTENTIAL CONFLICT OF INTEREST

Party #1’s Signature

Party #2’s Signature

Peter Robert Stone

AGREEMENT FOR

ELECTRONIC MESSAGING

AND STORAGE

Client Signature

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