Appendix C Personal Information Worksheet and Questionnaire

• Library: Premarital Agreements: Drafting and Negotiation (ABA) (2017 Ed.)

Appendix C

Personal Information Worksheet and Questionnaire

Personal information worksheet

For Premarital (or Postmarital) Agreement

Please provide the information requested below. This questionnaire is divided into two parts. The first part asks for personal information about you and your fiancé(e)/spouse. The second part asks for information about your financial affairs. Your responses will help us understand your objectives and evaluate your needs. The information you provide us, including the answers to the questions below, is confidential, meaning we will not share it with your fiancé(e)/spouse, or with his or her attorney, unless you authorize us to do so.

Today's Date:
Expected date of marriage:
Marriage will take place at:
If married, date of marriage:
Who referred you:
ABOUT MYSELF
1. Name:
2. Social security number:
3. Phone Numbers	O.K. to phone here?
	Yes	No
Home	[ ]	[ ]
Do you have caller ID on home phone?	[ ]	[ ]
Work	[ ]	[ ]
Mobile	[ ]	[ ]
Other	[ ]	[ ]
	Call before sending fax?
	Yes	No
Work Fax	[ ]	[ ]
Home Fax	[ ]	[ ]

4. Sex ___Age:___	Place of Birth:
Date of Birth:
Country(ies) of citizenship:
5. Addresses			Is this e-mail address password protected?
			Yes	No
Work e-mail:			[ ]	[ ]
Home e-mail:			[ ]	[ ]
Other e-mail:			[ ]	[ ]
Mailing address:
Should this be marked Personal & Confidential? [ ] No [ ] Yes
Residential address (if different):
County/state of residence:
How long resident of state (years/months):
6. Former name(s):
7.
Employer:		Position/occupation:
Address:
		Length of this employment:
		Usual work days/times:
		Approximate monthly gross pay:

8. Health problems for which special attention or care is necessary:

9. Education:
Level	Graduate? Yes No		Degree type/subject		Date	School
High School	[ ]	[ ]
Undergraduate	[ ]	[ ]
Graduate/Prof.	[ ]	[ ]
Doctorate	[ ]	[ ]
Post Doc	[ ]	[ ]
			Yes	No	Type of degree seeking	Expected date of graduation
Are you currently in school?			[ ]	[ ]

10. I was married___times before this marriage.1
	Former Spouse Name	Date marriage terminated	How terminated (death, divorce)
i.
ii.
iii.
iv.
v.

11. For each child born to or adopted by you:
Name	Age	Birth date	With whom does child reside?	School	Grade

12. Financial obligations to former spouse(s)/children:

13. Names and ages of any children of this marriage/relationship:
Name	Age	Birth date	With whom does child reside?	School	Grade

14. Major (nonroutine) financial obligations to children of current relationship (e.g., college expenses):

15. Do you have any stored embryos or other stored genetic material? If yes, please provide particulars.

16. Wills and estate planning:
	I do not have a will.
	I have a will executed on (date): .
	I have the following estate planning arrangements in place (e.g., annual cash gifts, revocable or irrevocable trust; life insurance trust, etc.):
	I have an estate planning attorney (Name):
	I do not have an estate planning attorney.

ABOUT MY FIANCE(E)/SPOUSE

17. Name:

18. Social security number:

19.	Phone Numbers	Note: We will not contact
		your fiancé(e)/spouse if he/she is represented by counsel.
Home
Does your fiancé(e)/spouse have caller ID on home phone? [ ] Yes [ ] No
Work
Mobile
Other
		Call before sending fax?
		Yes	No
Work Fax		[ ]	[ ]
Home Fax		[ ]	[ ]

20. Sex	Age:	Date of Birth:	Place of Birth:
21. Country(ies) of citizenship:
If not U.S. citizen, what is immigration status?
Did you sign an I-864 Form (Affidavit of Support) on behalf of your fiance(e)/spouse?

22. Addresses
Work e-mail:
Home e-mail:
Other e-mail:
Mailing address:	Residential address:
Should this be marked
personal & confidential? [ ] No [ ] Yes
23. County/state of residence:
How long resident of state:
24. Former name(s):
Employer:	Position/occupation:
Address:
	Length of this employment:
	Usual work days/times:
	Approximate monthly gross pay:
25. Health problems for which special attention or care is necessary:

26. Education:
Level		Graduate? Yes No		Degree type/subject				Date		School
High School		[ ]	[ ]
Undergraduate		[ ]	[ ]
Graduate/Prof.		[ ]	[ ]
Doctorate		[ ]	[ ]
Post Doc		[ ]	[ ]
					Yes	No	Type of degree seeking		Expected date of graduation
Is fiancé(e)/spouse currently in school?					[ ]	[ ]
27. Fiancé(e)/spouse currently has an attorney? [ ] Yes [ ] No
28. If yes, list contact information for opposing counsel if known:
	Attorney's name:
	Firm:
	Address:
	Phone:

29. My fiancé(e)/spouse was married__________times before the marriage.2
	Former Spouse Name	Date marriage terminated	How terminated (death, divorce)

30. For each child born or adopted into previous marriage(s)/relationships, list the following:
Name	Age	Birth date	With whom does child reside?	School	Grade
31. Financial obligations to former spouse(s), children:

32. Does fiancé(e)/spouse have any stored embryos or other stored genetic material? If yes, please provide particulars.

ABOUT THE MARRIAGE
33. Date:		Place:
What plans have already been made and/or carried out:
ABOUT THE PREMARITAL/POSTMARITAL AGREEMENT
34. Agreement is desired by:
Me	Fiancé(e)/Spouse		Both	Other
If other, please explain:
35. My objectives in seeking a premarital/postmarital agreement are:

36. My fiancé(e)'s/spouse's objectives in seeking a premarital /postmarital agreement are:

____________________

____________________

____________________

____________________

____________________

____________________

____________________

37. I foresee the following problems in dealing with my fiancé(e)/spouse regarding a premarital/postmarital agreement:

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

38. I have some questions and issues I would like to explore as follows:

____________________

____________________

____________________

____________________

____________________

____________________

39. I have already made some decisions about the terms I want included in the agreement, as follows:

____________________

____________________

____________________

____________________

____________________

____________________

FINANCIAL DISCLOSURE

Parties entering into a premarital/postmarital agreement should make disclosure of all assets, liabilities, and sources and amounts of income. A failure to do so may render the agreement unenforceable. You will have an opportunity to discuss with us any concerns you may have about the extent of the disclosure required to create an enforceable agreement in your particular case.

Please provide us with full and complete information about your financial circumstances. You may use the worksheet that begins on the following page if you wish. Also, please provide us with your fiancé(e)'s/spouse's financial disclosure, if possible. He/she may use the attached worksheet as well.

ASSETS AND DEBTS WORKSHEET
Name: ___ Date:___
1. Amounts and Sources of Income:
Source	Type*	Expected amt. this calendar year	Amt. last calendar year	Amt. 2 calendar years ago	Significant changes expected

* S = salary; P = pension; D = dividends; I = interest; C = capital gains; T = trust; R = rent; O = other

2. Real Estate:
Type**	Address	Date purchased	Price	Current value	Balance owed on mortgage	How titled?

** R = residence; I = investment/rental; U = unimproved land; F = farm or ranch; C = commercial property; V = vacation property (non-rental)

3. Automobiles and other motor vehicles (including...