ESTATE PLANNING INTAKE

Please complete this worksheet at your earliest convenience. Estimated values for assets and liabilities are fine. If you run out of space for any question, please include that information in the “Additional Information” section at the end of the worksheet.

Legal Name:*

Full Name

Also Known As:

Nickname, Alias, etc.

Birthdate:*

Date

Gender:*

YesNo

Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County:*

County

Home Phone:

Home PhoneFormat: (000) 000-0000.

Mobile Phone:

Mobile PhoneFormat: (000) 000-0000.

Home E-mail Address:

example@example.com

YesNo

Business:

Position:

Business Address:

Street Address

Street Address Line 2

CityState

Zip Code

County:

Business Phone:

Format: (000) 000-0000.

Business E-mail Address:

example@example.com

YesNo

Legal Name:

Also Known As:

Birthdate:

Date

Gender:

YesNo

Address (if different than yours):

Street Address

Street Address Line 2

CityState

Zip Code

County:

Phone:

Mobile PreferredFormat: (000) 000-0000.

E-mail Address:

example@example.com

If child is married, spouse’s name:

If child is deceased, date of death:

Date

Child's Children & Birthdates:

Legal Names

YesNo

Legal Name:

Also Known As:

Birthdate:

Date

Gender:

YesNo

Address (if different than yours):

Street Address

Street Address Line 2

CityState

Zip Code

County:

Phone:

Mobile PreferredFormat: (000) 000-0000.

E-mail Address:

example@example.com

If child is married, spouse’s name:

If child is deceased, date of death:

Date

Child's Children & Birthdates:

Legal Names

YesNo

Legal Name:

Also Known As:

Birthdate:

Date

Gender:

YesNo

Address (if different than yours):

Street Address

Street Address Line 2

CityState

Zip Code

County:

Phone Number:

Mobile PreferredFormat: (000) 000-0000.

E-mail Address:

example@example.com

If child is married, spouse’s name:

If child is deceased, date of death:

Date

Child's Children & Birthdates:

Legal Names

YesNo

Legal Name:

Legal Name

Also Known As:

Relationship to You:

YesNo

Birthdate:

Date

Gender:

Address

Street Address

Street Address Line 2

CityState

Zip Code

County:

Phone:

Mobile PreferredFormat: (000) 000-0000.

E-mail Address:

example@example.com

YesNo

Legal Name:

Also Known As:

Relationship to You:

Birthdate:

Date

Gender:

YesNo

Address

Street Address

Street Address Line 2

CityState

Zip Code

County:

Phone:

Mobile PreferredFormat: (000) 000-0000.

E-mail Address:

example@example.com

YesNo

Name:

Type of Animal (Dog, Cat):

Age:

Years

YesNo

Name:

Type of Animal (Dog, Cat):

Age:

YesNo

Name:

Phone:

Format: (000) 000-0000.

Business E-mail:

example@example.com

YesNo

Name:

Phone:

Format: (000) 000-0000.

Business E-mail Address:

example@example.com

YesNo

Name:

Phone:

Format: (000) 000-0000.

Business E-mail Address:

example@example.com

YesNo

Name:

Phone:

Format: (000) 000-0000.

Business E-mail Address:

example@example.com

Yes (please email copy of the documents)No

YesNo

Please explain:

Yes (please email a copy of the order)No

Yes (if federal estate or state death tax return was filed, please email copies)No

Yes (please email a copy of the returns)No

YesNo

Please explain:

YesNo

Please explain:

YesNoNot Applicable

Please explain:

YesNoNot Applicable

Please explain:

YesNo

Please explain:

YesNo

Please explain:

YesNo

General Description and/or Address:

Owner [Self/Trust/Jointly with Others]:

Estimated Current Market Value:

Outstanding Mortgage Balance (if any):

YesNo

General Description and/or Address:

Owner [Self/Trust/Jointly with Others]:

Estimated Current Market Value:

Outstanding Mortgage Balance (if any):

YesNo

General Description and/or Address:

Owner [Self/Trust/Jointly with Others]:

Estimated Current Market Value:

Outstanding Mortgage Balance (if any):

YesNo

1st - General Description:

Owner [Self/Trust/Jointly with Others]:

Estimated Market Value:

YesNo

2nd - General Description:

Owner [Self/Trust/Jointly with Others]:

Estimated Market Value:

YesNo

1st - General Description:

Owner [Self/Trust/Jointly with Others]:

Estimated Current Market Value:

Outstanding Debt?

YesNo

2nd - General Description:

Owner [Self/Trust/Jointly with Others]:

Estimated Current Market Value:

Outstanding Dept?

YesNo

Name of 1st Institution:

Type of Account:

Owner [Self/Trust/Jointly with Others]:

Current Balance:

YesNoUnsure

Who is the transfer-on-death beneficiary?

Name of 2nd Institution:

Type of Account:

Owner [Self/Trust/Jointly with Others]:

Current Balance

YesNoUnsure

Who is the transfer-on-death beneficiary?

Name of 3rd Institution:

Type of Account:

Owner [Self/Trust/Jointly with Others]:

Current Balance:

YesNoUnsure

If yes, who is the transfer-on-death beneficiary?

YesNo

Name of 1st Institution:

Type of Account:

Current Balance:

YesNoUnsure

If yes, who is the primary beneficiary?

If yes, who is the secondary beneficiary?

Name of 2nd Institution:

Type of Account:

Current Balance:

YesNoUnsure

If yes, who is the primary beneficiary?

If yes, who is the secondary beneficiary?

Name of 3rd Institution:

Type of Account:

Current Balance:

YesNoUnsure

If yes, who is the primary beneficiary?

If yes, who is the secondary beneficiary?

YesNo

Name of 1st Institution:

Owner [Self/Trust/Jointly with Others]:

Current Balance:

YesNoUnsure

If yes, who is the transfer-on-death beneficiary?

Name of 2nd Institution:

Owner [Self/Trust/Jointly with Others]:

Current Balance:

YesNoUnsure

If yes, who is the transfer-on-death beneficiary?

Name of 3rd Institution:

Owner [Self/Trust/Jointly with Others]:

Current Balance:

YesNoUnsure

If yes, who is the transfer-on-death beneficiary?

YesNo

Name of 1st Institution:

Type of Policy [Term Life/Whole Life/Variable Life/Universal Life/Group Term Life (Employer-Provided)/Annuity]:

Amount of Death Benefit:

Current Cash Value (if any):

Owner of Policy [Self/Trust/Employer/Other]:

Insured [Self/Other]:

Primary Beneficiary [Children/Trust/Other]:

Secondary Beneficiary [Children/Trust/Other]:

Name of 2nd Institution:

Type of Policy [Term Life/Whole Life/Variable Life/Universal Life/Group Term Life (Employer-Provided)/Annuity]:

Amount of Death Benefit:

Current Cash Value (if any):

Owner of Policy [Self/Trust/Employer/Other]:

Insured [Self/Other]:

Primary Beneficiary [Children/Trust/Other]:

Secondary Beneficiary [Children/Trust/Other]:

YesNo

1st Business Name

Type of Business [LLC/S-Corporation/C-Corporation/Limited Partnership/General Partnership/Other]:

Description of Business:

Ownership Percentage:

Estimated Value of Entire Business:

Owner [Self/Trust/Other]:

Other Owners (if any):

YesNo

2nd Business Name

Type of Business [LLC/S-Corporation/C-Corporation/Limited Partnership/General Partnership/Other]:

Description of Business:

Ownership Percentage:

Estimated Value of Entire Business:

Owner [Self/Trust/Other]:

Other Owners (if any):

YesNo

Name of 1st Debtor:

Name of Lender [Self/Trust/Other]:

Original Date of Loan:

Date

Maturity Date:

Date

Outstanding Balance

YesNo

Name of 2nd Debtor:

Name of Lender [Self/Trust/Other]:

Original Date of Loan:

Date

Maturity Date:

Date

Outstanding Balance:

YesNo

If yes, please explain:

YesNo

If yes, please explain:

YesNo

Name of 1st Lender:

Name of Debtor [Self/Trust/Other]:

Purpose of Loan:

Original Date of Loan:

Date

Maturity Date:

Date

Outstanding Balance:

YesNo

Name of 2nd Lender:

Name of Debtor [Self/Trust/Other]:

Purpose of Loan:

Original Date of Loan:

Date

Maturity Date:

Date

Outstanding Balance:

YesNo

Please provide any additional information you would like to include:

ESTATE PLANNING INTAKE

BIOGRAPHICAL INFORMATION

CHILDREN

1st CHILD

2nd CHILD

3rd CHILD

OTHER IMPORTANT FRIENDS OR FAMILY MEMBERS

1st FRIEND OR FAMILY MEMBER

2nd FRIEND OR FAMILY MEMBER

PETS

PROFESSIONAL ADVISORS

CPA / ACCOUNTANT

FINANCIAL / WEALTH MANAGEMENT ADVISOR

LIFE INSURANCE AGENT

BUSINESS, TAX or OTHER ATTORNEYS

IMPORTANT QUESTIONS

PROPERTY INFORMATION

PROPERTY 1

PROPERTY 2

PROPERTY 3

SIGNIFICANT PERSONAL PROPERTY

AUTOMOBILES, BOATS, RVs or OTHER VEHICLES

DEPOSIT ACCOUNTS

RETIREMENT PLANS

TAXABLE INVESTMENT ACCOUNTS

LIFE INSURANCE POLICIES OR ANNUITIES

CLOSELY HELD BUSINESS INTERESTS

DEBTORS

GIFTS, INHERITANCES AND OTHER ASSETS

OTHER DEBT

ADDITIONAL INFORMATION