100 East Broad Street, Suite 2320, Columbus, Ohio 43215

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: