ESTATE PLANNING INTAKE

ESTATE PLANNING INTAKE

WORKSHEET FOR INDIVIDUAL
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.
BIOGRAPHICAL INFORMATION
Legal Name:*
Full Name
Also Known As:
Nickname, Alias, etc.
Birthdate:*

MonthDayYear
Date
Gender:*
US Citizen?*

YesNo
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County:*
County
Home Phone:
Home Phone
Mobile Phone:
Mobile Phone
Home E-mail Address:
example@example.com
Are You Currently Employed?*

YesNo
Business:
Position:
Business Address:

Street Address

Street Address Line 2

CityState

Zip Code
County:
Business Phone:
Business E-mail Address:
example@example.com
CHILDREN
Do you now or have you ever had children?*

YesNo
1st CHILD
Legal Name:
Also Known As:
Birthdate:

MonthDayYear
Date
Gender:
US Citizen?

YesNo
Address (if different than yours):

Street Address

Street Address Line 2

CityState

Zip Code
County:
Phone:
Mobile Preferred
E-mail Address:
example@example.com
If child is married, spouse’s name:
If child is deceased, date of death:

MonthDayYear
Date
Child's Children & Birthdates:
Legal Names
Do You Have a 2nd Child?

YesNo
2nd CHILD
Legal Name:
Also Known As:
Birthdate:

MonthDayYear
Date
Gender:
US Citizen?

YesNo
Address (if different than yours):

Street Address

Street Address Line 2

CityState

Zip Code
County:
Phone:
Mobile Preferred
E-mail Address:
example@example.com
If child is married, spouse’s name:
If child is deceased, date of death:

MonthDayYear
Date
Child's Children & Birthdates:
Legal Names
Do You Have a 3rd Child?

YesNo
3rd CHILD
Legal Name:
Also Known As:
Birthdate:

MonthDayYear
Date
Gender:
Citizen?

YesNo
Address (if different than yours):

Street Address

Street Address Line 2

CityState

Zip Code
County:
Phone Number:
Mobile Preferred
E-mail Address:
example@example.com
If child is married, spouse’s name:
If child is deceased, date of death:

MonthDayYear
Date
Child's Children & Birthdates:
Legal Names
OTHER IMPORTANT FRIENDS OR FAMILY MEMBERS
Are there any important friends or family members that you may include in your estate plan (for example, as a beneficiary or executor of your estate)?*

YesNo
1st FRIEND OR FAMILY MEMBER
Legal Name:
Legal Name
Also Known As:
Relationship to You:
US Citizen?

YesNo
Birthdate:

MonthDayYear
Date
Gender:
Address

Street Address

Street Address Line 2

CityState

Zip Code
County:
Phone:
Mobile Preferred
E-mail Address:
example@example.com
Add Another Friend or Family Member?

YesNo
2nd FRIEND OR FAMILY MEMBER
Legal Name:
Also Known As:
Relationship to You:
Birthdate:

MonthDayYear
Date
Gender:
US Citizen?

YesNo
Address

Street Address

Street Address Line 2

CityState

Zip Code
County:
Phone:
Mobile Preferred
E-mail Address:
example@example.com
PETS
Do you have any pets?*

YesNo
Name:
Type of Animal (Dog, Cat):
Age:
Years
Another pet?

YesNo
Name:
Type of Animal (Dog, Cat):
Age:
PROFESSIONAL ADVISORS
CPA / ACCOUNTANT
Do you have a CPA or accountant?*

YesNo
Name:
Phone:
Business E-mail:
example@example.com
FINANCIAL / WEALTH MANAGEMENT ADVISOR
Do you have a financial or wealth management advisor?*

YesNo
Name:
Phone:
Business E-mail Address:
example@example.com
LIFE INSURANCE AGENT
Do you have a life insurance agent?*

YesNo
Name:
Phone:
Business E-mail Address:
example@example.com
BUSINESS, TAX or OTHER ATTORNEYS
Do you have other attorneys (business, tax, etc.)*

YesNo
Name:
Phone:
Business E-mail Address:
example@example.com
IMPORTANT QUESTIONS
Have you completed previous will, trust or estate planning?*

Yes (please email copy of the documents)No
Are you receiving Social Security, disability, or other governmental benefits?*

YesNo
Please explain:
Are you making payments pursuant to a divorce or property settlement order?*

Yes (please email a copy of the order)No
Have you ever been widowed?*

Yes (if federal estate or state death tax return was filed, please email copies)No
Have you ever filed a federal or state gift tax return?*

Yes (please email a copy of the returns)No
Have you chosen any charitable organizations that you wish to make provisions for at the time of your death?*

YesNo
Please explain:
To your knowledge, are you the current or remainder beneficiary of anyone else’s revocable or irrevocable trust (parents, grandparents)?*

YesNo
Please explain:
Do any of your children have special educational, medical or physical needs?*

YesNoNot Applicable
Please explain:
Do any of your children receive governmental support or benefits?*

YesNoNot Applicable
Please explain:
Do you provide primary or other major financial support to adult children or others?*

YesNo
Please explain:
Are there any specific goals or concerns that you would like to address in your estate plan?*

YesNo
Please explain:
PROPERTY INFORMATION
Do you own any real estate (personal residence, vacation home, vacant land, timeshare)?*

YesNo
PROPERTY 1
General Description and/or Address:
Owner [Self/Trust/Jointly with Others]:
Estimated Current Market Value:
Outstanding Mortgage Balance (if any):
Is there a 2nd Property?

YesNo
PROPERTY 2
General Description and/or Address:
Owner [Self/Trust/Jointly with Others]:
Estimated Current Market Value:
Outstanding Mortgage Balance (if any):
Is there a 3rd Property?

YesNo
PROPERTY 3
General Description and/or Address:
Owner [Self/Trust/Jointly with Others]:
Estimated Current Market Value:
Outstanding Mortgage Balance (if any):
SIGNIFICANT PERSONAL PROPERTY
Other than ordinary household furnishings and personal effects, do you own any personal property of significant financial value (jewelry, artwork, collectibles, etc)?*

YesNo
1st - General Description:
Owner [Self/Trust/Jointly with Others]:
Estimated Market Value:
Insured?

YesNo
2nd - General Description:
Owner [Self/Trust/Jointly with Others]:
Estimated Market Value:
Insured?

YesNo
AUTOMOBILES, BOATS, RVs or OTHER VEHICLES
Do you own any automobiles, boats, recreational vehicles (RV) or other vehicles?*

YesNo
1st - General Description:
Owner [Self/Trust/Jointly with Others]:
Estimated Current Market Value:
Outstanding Debt?
Insured?

YesNo
2nd - General Description:
Owner [Self/Trust/Jointly with Others]:
Estimated Current Market Value:
Outstanding Dept?
Insured?

YesNo
DEPOSIT ACCOUNTS
Do you own any deposit accounts (checking, savings, money market, CDs)?*

YesNo
Name of 1st Institution:
Type of Account:
Owner [Self/Trust/Jointly with Others]:
Current Balance:
Have you named a transfer-on-death beneficiary?

YesNoUnsure
Who is the transfer-on-death beneficiary?
Name of 2nd Institution:
Type of Account:
Owner [Self/Trust/Jointly with Others]:
Current Balance
Have you named a transfer-on-death beneficiary?

YesNoUnsure
Who is the transfer-on-death beneficiary?
Name of 3rd Institution:
Type of Account:
Owner [Self/Trust/Jointly with Others]:
Current Balance:
Have you named a transfer-on-death beneficiary?

YesNoUnsure
If yes, who is the transfer-on-death beneficiary?
RETIREMENT PLANS
Do you own any retirement plans (401(k), 403(b), Traditional or Roth IRAs, etc)?*

YesNo
Name of 1st Institution:
Type of Account:
Current Balance:
Have you named a primary and secondary beneficiary?

YesNoUnsure
If yes, who is the primary beneficiary?
If yes, who is the secondary beneficiary?
Name of 2nd Institution:
Type of Account:
Current Balance:
Have you named a primary and secondary beneficiary?

YesNoUnsure
If yes, who is the primary beneficiary?
If yes, who is the secondary beneficiary?
Name of 3rd Institution:
Type of Account:
Current Balance:
Have you named a primary and secondary beneficiary?

YesNoUnsure
If yes, who is the primary beneficiary?
If yes, who is the secondary beneficiary?
TAXABLE INVESTMENT ACCOUNTS
Do you own any taxable investment accounts?*

YesNo
Name of 1st Institution:
Owner [Self/Trust/Jointly with Others]:
Current Balance:
Have you named a transfer-on-death beneficiary?

YesNoUnsure
If yes, who is the transfer-on-death beneficiary?
Name of 2nd Institution:
Owner [Self/Trust/Jointly with Others]:
Current Balance:
Have you named a transfer-on-death beneficiary?

YesNoUnsure
If yes, who is the transfer-on-death beneficiary?
Name of 3rd Institution:
Owner [Self/Trust/Jointly with Others]:
Current Balance:
Have you named a transfer-on-death beneficiary?

YesNoUnsure
If yes, who is the transfer-on-death beneficiary?
LIFE INSURANCE POLICIES OR ANNUITIES
Are you the owner, insured or beneficiary of any life insurance policies or annuities?*

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]:
CLOSELY HELD BUSINESS INTERESTS
Do you own any closely held business interests?*

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):
Have you entered into any Shareholder Agreements, Operating Agreements or Buy-Sell Agreements?

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):
Have you entered into any Shareholder Agreements, Operating Agreements or Buy-Sell Agreements?

YesNo
DEBTORS
Does anyone owe any money to you?*

YesNo
Name of 1st Debtor:
Name of Lender [Self/Trust/Other]:
Original Date of Loan:

MonthDayYear
Date
Maturity Date:

MonthDayYear
Date
Outstanding Balance
Secured?

YesNo
Did you document the loan with a written Promissory Note?

YesNo
Name of 2nd Debtor:
Name of Lender [Self/Trust/Other]:
Original Date of Loan:

MonthDayYear
Date
Maturity Date:

MonthDayYear
Date
Outstanding Balance:
Secured?

YesNo
Did you document the loan with a written Promissory Note?

YesNo
GIFTS, INHERITANCES AND OTHER ASSETS
Do you anticipate receiving any gifts or inheritances from a third party (parents, grandparents, trust distributions) at some time in the future?*

YesNo
If yes, please explain:
Do you have any other significant assets that do not fit into any of the above categories (whether significant for financial or sentimental reasons)?*

YesNo
If yes, please explain:
OTHER DEBT
Other than mortgages and loans already referenced above, do you have any outstanding debt?*

YesNo
Name of 1st Lender:
Name of Debtor [Self/Trust/Other]:
Purpose of Loan:
Original Date of Loan:

MonthDayYear
Date
Maturity Date:

MonthDayYear
Date
Outstanding Balance:
Secured?

YesNo
Name of 2nd Lender:
Name of Debtor [Self/Trust/Other]:
Purpose of Loan:
Original Date of Loan:

MonthDayYear
Date
Maturity Date:

MonthDayYear
Date
Outstanding Balance:
Secured?

YesNo
ADDITIONAL INFORMATION
Please provide any additional information you would like to include:
Should be Empty:

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