ESTATE PLANNING CHECKLIST

ESTATE PLANNING CHECKLIST 

SECTION 1 – FAMILY INFORMATION 

A. Yourself. Date: 

1. Your name: 

2. Other names by which you are known (e.g., maiden name) 

3. Your home address and phone/e-mail 

4. Your county of residence: 

5. Your social security #: 

6. Your date of birth: 

7. Your place of birth: 

8. Your citizenship: 

9. Your occupation: 

10. Your business address, phone, fax and e-mail: 

11. General state of health: 

12. Date of marriage: 

13. Any prior marriages – divorces, separations, annulments, etc. 

14. Do you have a premarital agreement (or similar agreement) between you and your 

spouse (If yes, please attach a copy) 

B. Spouse. 

1. Spouse’s name: 

2. Other names by which spouse is known (e.g., maiden name) 

3. Spouse’s social security #: 

4. Spouse’s date of birth: 

5. Spouse’s place of birth: 

6. Spouse’s citizenship: 

7. Spouse’s occupation: 

8. Spouse’s business address, phone and fax: 

9. General state of health: 

10. Any prior marriages – divorces, separations, annulments, etc.

C. Children (including adopted children and stepchildren). 

Do you anticipate any more children 

Are any children adopted or stepchildren 

Are you or anyone in your family disabled 

Does anyone in your family receive government benefits 

If yes, when did these benefits start. 

Child 1 

1. Name: 

2. Address and Phone Number: 

3. Date of birth: 

4. If deceased, date of death: 

5. Place of birth: 

6. If married, spouse’s name: 

7. Stability of marriage 

8. Any children born of the child’s marriage If yes, list names and birth dates. 

Child 2 

1. Name: 







8. Any children born of the child’s marriage If yes, list names and birth dates.

Child 3 

1. Name: 








Child 4 

1. Name: 








Child 5 

1. Name: 







8. Any children born of the child’s marriage If yes, list names and birth dates.

D. Your Closet Living Relatives. 

Father: 

Address: 

Age: 

Mother: 

Address: 

Age: 

Sibling: 

Address: 

Age: 

Sibling: 

Address: 

Age: 

Sibling: 

Address: 

Age: 

E. Your Spouse’s Closest Living Relatives. 

Father: 

Address: 

Age: 

Mother: 

Address: 

Age: 

Sibling: 

Address: 

Age: 

Sibling: 

Address: 

Age:

Sibling: 

Address: 

Age: 

SECTION 2 – MISCELLANEOUS 

A. Do you or your spouse own any assets located outside the State of Michigan (If 

yes, please describe the asset and its location.) 

B. Have you or your spouse ever lived in a community property state (Arizona, 

California, Idaho, Louisiana, Nevada, New Mexico, Texas, or Washington) 

C. Do you have a safe deposit box (If yes, please give the name of the bank and the 

number of the box.) 

D. Excluded Heirs. 

Is there anyone who you or your spouse would wish to exclude from any portion 

of your estate (If yes, please identify) 

E. Do any persons owe you money If so, provide the name of the borrower and the 

amount outstanding. 

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SECTION 3 – ASSETS 

D. Assets – Please Enter Approximate Dollar Amounts. Single individuals 

please use fist and third columns only. 

1. Real estate 

a. Home-present value 

b. (Less mortgage) 

Home equity 

c. Other real estate 

d. Other real estate 

2. Bank accounts and CDs 

a. Savings 

b. Checking 

c. Certificate of Deposit 

d. Money Market Accounts 

3. Marketable stocks 

a. You Hold Certificates 

b. Brokerage Account 

4. Bonds 

5. Mutual Funds 

6. Notes & Loan receivable 

7. Life Insurance 

8. Closely-held business 

9. Pension & retirement benefits 

10. Personal nonbusiness property 

11. Annuities 

12. Individual Retirement Accts 

13. Other Assets (describe) 

a. 

b. 

c. 

Husband Wife Joint 

( ) ( ) ( ) 

TOTAL ASSETS 

When was the last time your Homeowner’s Insurance and Auto Insurance Policies were 

reviewed 

Do you have long term care insurance 

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SECTION 4 – ESTATE PLANNING DOCUMENTS TO BE PREPARED 

A. Trustee Matters 

1) Trustee 

Name: 

Address and Phone Number: 

Social Security Number: 

Relationship: 

2) Alternate Trustee 

Name: 


Social Security Number: 

Relationship: 

B. Durable Power of Attorney. 

1) Person to have power of attorney: 

Name: 


Relationship: 

2) Alternate person to have power of attorney: 

Name: 


Relationship:

C. Medical Directive (also known as “Living Will” and Medical Power of 

Attorney. 

1) Person to make decision concerning your health care in the event you are 

unable to make your own decisions. 

Name: 


Relationship: 

2) Alternate person to make decisions concerning your health care in the 

event you are unable to make your own decisions. 

Name: 


Relationship: 

D. Guardian For Minor or Person With Disability. 

1) Person(s) to have care and custody of your children in the event both of 

you are deceased or unable. 

Name(s): 


Relationship: 

2) Alternate person(s): 


Relationship:

PLEASE FILL OUT FOR ANY SIGNIFICANT FAMILY MEMBER IN 

YOUR ESTATE PLAN WITH A DISABILITY 

INSTRUCTIONS 

PURPOSE: TO PROVIDE CURRENT INFORMATION REGARDING THE HISTORY OF [INSERT DISABLED 

PERSON’S NAME] _________________, THE DAILY AND WEEKLY ROUTINES, AND RELATIONSHIPS AND 

ACTIVITIES THAT CONTRIBUTE TO HIS/HER QUALITY OF LIFE. 

COMPLETION AND REVIEW: TO BE COMPLETED BY ________________ [PARENT(S)] AND REVISED AS 

NECESSARY. 

ATTACH SUPPLEMENTAL NOTES AS NECESSARY 

GENERAL INFORMATION 

PLEASE INSERT DISABLED PERSON’S 

NAME BELOW. 

___________________ 

PREFERS TO BE CALLED: 

SOCIAL SECURITY NUMBER: 

HEIGHT, WEIGHT: 

CLOTHING AND SHOE SIZES: 

DATE OF BIRTH: 

CITY WHERE RAISED: 

MEDICAL INFORMATION – HISTORY, CURRENT STATUS AND CARE REQUIREMENTS 

Diagnosis – primary diagnoses of condition and physical limitations: 

MEDICAL COMPLICATIONS: 

SEIZURES (HISTORY, CURRENT STATUS): 

INTELLECTUAL FUNCTIONING:

VISION – STATUS OF VISION, NEED FOR GLASSES, DATE OF LAST EYE EXAM: 

HEARING – NORMAL, NEED HEARING AID, ETC.: 

SPEECH/ COMMUNICATIONS – NORMAL, IMPAIRED, DIFFICULT TO UNDERSTAND: 

MOBILITY – ASSISTANCE NEEDED, ASSISTIVE DEVICES USED: 

HEATH INSURANCE COVERAGE (COMPANY AND POLICY NUMBERS): 

CURRENT PHYSICIANS AND HEALTH PRACTITIONERS (NAME, LOCATION, AND SPECIALTY): 

FORMER PHYSICIANS (NAME, LOCATION, AND SPECIALTY): 

DOES DISABLED PERSON CURRENTLY NEED NURSING CARE IF YES, DESCRIBE PLACE AND TYPE REQUIRED 

(CLINIC, HOME, ETC.)

MENTAL HEALTH PRACTITIONERS CURRENTLY TREATING DISABLED PERSON (NAME, LOCATION) 

THERAPY – IS DISABLED PERSON CURRENTLY UNDERGOING ANY TYPE OF THERAPY (PHYSICAL, SPEECH, OR 

OCCUPATIONAL) IF YES, LIST NAME(S) OF THERAPIST(S), SPECIALTY AND LOCATION: 

DIAGNOSTIC TESTING – LIST ANY DIAGNOSTIC TESTS REGULARLY UNDERGONE BY DISABLED PERSON (PURPO 

LOCATION, FREQUENCY): 

IMMUNIZATIONS – TYPE AND DATES OF IMMUNIZATIONS DISABLED PERSON HAS RECEIVED: 

DISEASES – CHILDHOOD AND ADULTHOOD, DATES AND TYPES 

OPERATIONS OR OTHER HOSPITALIZATION (DATES, PURPOSE, LOCATION): 

ALLERGIES AND CURRENT TREATMENT: 

PARENTS’ OF DISALED PERSON AND THEIR RESPECTIVE HEALTH HISTORIES, CURRENT CONDITION:

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ESTATE PLANNING CHECKLIST

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