Beneficiary Questionnaire Who Will Receive Which of Your Assets? Spouse Spouse________________________________________________________________________ ______________________________________________________________________________ _____________________________________________ Maiden name __________________________________________________________ Date of marriage ________________________________________________________ Date of birth ___________________________________________________________ Address Current income ..................................................................................$_____________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Children Child_________________________________________________________________________ ______________________________________________________________________________ ________________________________________________ Date of birth ___________________________________________________________ Address Spouse's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Child_________________________________________________________________________ ______________________________________________________________________________ ________________________________________________ Date of birth ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Child_________________________________________________________________________ ______________________________________________________________________________ ________________________________________________ Date of birth ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Child_________________________________________________________________________ ______________________________________________________________________________ ________________________________________________ Date of birth ___________________________________________________________ Address Spouse's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Child_________________________________________________________________________ ______________________________________________________________________________ ________________________________________________ Date of birth ___________________________________________________________ Address Spouse's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Child_________________________________________________________________________ ______________________________________________________________________________ ________________________________________________ Date of birth ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Grandchildren Grandchild _______________________________________________________________ Date of birth ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Grandchild _______________________________________________________________ Date of birth ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Grandchild _______________________________________________________________ Date of birth ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Grandchild _______________________________________________________________ Date of birth ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Parents Parent________________________________________________________________________ ______________________________________________________________________________ _______________________________________________ Date of birth ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Parent________________________________________________________________________ ______________________________________________________________________________ _______________________________________________ Date of birth ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Siblings Sibling________________________________________________________________________ ______________________________________________________________________________ _____________________________________________ Date of birth ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Sibling________________________________________________________________________ ______________________________________________________________________________ _____________________________________________ Date of birth ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Sibling________________________________________________________________________ ______________________________________________________________________________ _____________________________________________ Date of birth ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Sibling________________________________________________________________________ ______________________________________________________________________________ _____________________________________________ Date of birth ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Sibling________________________________________________________________________ ______________________________________________________________________________ _____________________________________________ Date of birth ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Sibling________________________________________________________________________ ______________________________________________________________________________ _____________________________________________ Date of birth ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Other Dependents Other Dependent __________________________________________________________ Date of birth ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Other Dependent __________________________________________________________ Date of birth ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Other Dependent __________________________________________________________ Date of birth ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Other Dependent __________________________________________________________ Date of birth ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Are There Any Other Relatives, Friends, or Organizations to Whom You Wish to Leave Gifts? Name_________________________________________________________________________ ______________________________________________________________________________ ______________________________________________ Relationship ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Name_________________________________________________________________________ ______________________________________________________________________________ ______________________________________________ Relationship ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Name_________________________________________________________________________ ______________________________________________________________________________ ______________________________________________ Relationship ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Name_________________________________________________________________________ ______________________________________________________________________________ ______________________________________________ Relationship ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Name_________________________________________________________________________ ______________________________________________________________________________ ______________________________________________ Relationship ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Name_________________________________________________________________________ ______________________________________________________________________________ ______________________________________________ Relationship ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Name_________________________________________________________________________ ______________________________________________________________________________ ______________________________________________ Relationship ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Name_________________________________________________________________________ ______________________________________________________________________________ ______________________________________________ Relationship ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Amount, specific items, or share of estate that you desire to leave Alternate beneficiary ____________________________________________________ Are There Any Persons Whom You Wish to Specifically Leave out of Your Will? Name_________________________________________________________________________ ______________________________________________________________________________ ______________________________________________ Relationship ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Reason for disinheritance Name_________________________________________________________________________ ______________________________________________________________________________ ______________________________________________ Relationship ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Reason for disinheritance Name_________________________________________________________________________ ______________________________________________________________________________ ______________________________________________ Relationship ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Reason for disinheritance Name_________________________________________________________________________ ______________________________________________________________________________ ______________________________________________ Relationship ___________________________________________________________ Address Spouse 's name (if any)___________________________________________________ Reason for disinheritance