100 East Broad Street, Suite 2320, Columbus, Ohio 43215
1-614-469-4778

Questionnaire

If you would like to be contacted by Becker & Lilly, LLC to discuss your estate planning needs, please complete the Questionnaire below and Submit it. One of our attorneys will contact you within 24 hours to discuss our potential representation. All information is kept in strict confidence and will be deleted/destroyed upon your request. We look forward to speaking with you.

-Becker & Lilly, LLC

Begin Questionnaire

Do you currently have an estate plan? *
YesNo

If yes, have events in your life such as changes in marital status, birth of new children or grandchildren, family deaths, retirements, change of residence to another state, length of time, changes in state, federal or gift tax law prompted you to want to have your current plan reviewed for possible updating? *
YesNo

Section 1 -- Please Tell Us About You

Your Name: *

If you are married, your Spouse's Name:

Home Address:

Telephone Number:

E-mail Address: *

Your Occupation:

Your Spouse's Occupation

Date/Place of Marriage:

Special Medical Situation:

Have you been married before? *
YesNo

Has your spouse been married before? *
YesNo

Section 2 -- Please Tell Us About Your Family

Your Children

Child 1: *
YesNo

a. Name:

Child of: *
BothHusbandWife

Date of Birth:

Special Medical Situation:

Spouse's Name

Children of this child:
Name:

Date of Birth:

Name:

Date of Birth:

Child 2:*
YesNo

b. Name:

Child of: *
BothHusbandWife

Date of Birth:

Special Medical Situation:

Spouse's Name

Children of this child:
Name:

Date of Birth:

Name:

Date of Birth:

Other Potential Beneficiaries:
Section 3 -- Please Tell Us About Your Net Worth and Business Interests

Your Net Worth:

Real Estate

You:

Your Spouse:

Joint:

Investments/Cash

You:

Your Spouse:

Joint:

Retirement Plans

You:

Your Spouse:

Joint:

Business

You:

Your Spouse:

Joint:

Personal Property

You:

Your Spouse:

Joint:

Total Assests

You:

Your Spouse:

Joint:

Real Estate

You:

Your Spouse:

Joint:

Business Interests

Do You Own a Business? *
YesNo

Name of Business:

Nature of Business:

Kind of Entity: *
Sole ProprietorshipPartnershipLimited Liability CompanyC CorporationS Corporation

If other: (explain)

Percentage of interest owned:

By You:

By Your Spouse:

By Others:

Children involved in the business:

Name of Child:

Percentage Owned:

Name of Child:

Percentage Owned:

If you have other information you believe to be pertinent, please add it here: