ESTATE PLANNING CLIENT INTAKE FORM
Please complete this Estate Planning Client Intake Form to the best of your knowledge. I ask that you provide as much detail as possible so that I can accurately evaluate your situation and properly advise you regarding your estate planning options. All information provided with this Intake Form will be held in strict confidence.
When filling out this Intake Form please use full legal names and make sure that the names of any party listed are spelled correctly. If more space is needed, please feel free to attach additional pages as necessary. If you are unsure about how to answer some of the questions, simply indicate on the form that you would like to discuss the subject matter at our initial consultation.
Please complete and return this form to me via email or mail at least 24 hours prior to our initial consultation. I look forward to working with you.
CLIENT INFORMATION:
CLIENT #1
CLIENT #2
First Name
Middle Name
Last Name
Nickname (if any)
Date and place of birth
Country of citizenship
Home address
City, state, zip
County of residence
Home phone
Mobile phone
Email
Employer (or retired if applicable)
Last 4 digits of SSN
Military Service (Y/N) & Dates of Service
Married (Y/N)
When were the clients married?
Spouse’s Name (if applicable)
Previous Marriage(s):
Dates
Ex-Spouse’s Name
Reason for Ending
Obligations to Ex-spouse?
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CHILDREN:
FULL LEGAL NAME
D.O.B.
GENDER
CHILD OF
1.
2.
3.
OTHER DEPENDENTS:
FULL LEGAL NAME
GENDER
RELATIONSHIP
1.
2.
3.
ADDITIONAL CLIENT INFORMATION:
Are you or your spouse currently receiving social security, disability,or other governmental benefits?
Yes
No
N/A
Have you or your spouse signed a pre- or post-marriage agreement?
Yes
No
N/A
Do you or your spouse have a prior will, trust or other estate planning documents? If yes, please provide with this Intake.
Yes
No
N/A
Do you own any property in any state other than Montana?
Yes
No
N/A
Are any of you your children disabled or institutionalized?
Yes
No
N/A
If yes to above, do those children receive any governmental benefits as a result of their disability or institutionalization?
Yes
No
N/A
PLANNING CONSIDERATIONS:
Personal Representative: The person who will administer your estate in probate after you die.
Personal Representative: The person who will administer your estate in probate after you die.
CLIENT #1
1st Choice
2st Choice
3st Choice
CLIENT #2
1st Choice
2st Choice
3st Choice
Danielle M. Shyne, Shyne Law Group, Estate Planning Intake Form
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Successor Trustee:
The person who will manage your trust if you become incapacitated or administer your trust after you die.
CLIENT #1
1st Choice
2st Choice
3st Choice
CLIENT #2
1st Choice
2st Choice
3st Choice
Durable Financial Power of Attorney:
The person who can make financial, legal, and property decisions on your behalf if you become incapacitated.
CLIENT #1
1st Choice
2st Choice
3st Choice
CLIENT #2
1st Choice
2st Choice
3st Choice
Durable Healthcare Power of Attorney:
The person who can make healthcare decisions on your behalf if you become incapacitated.
CLIENT #1
1st Choice
2st Choice
3st Choice
CLIENT #2
1st Choice
2st Choice
3st Choice
Guardians for Minor Children:
The person(s) responsible for raising your minor children in the event that you and your spouse die.
CLIENT #1
1st Choice
2st Choice
3st Choice
CLIENT #2
1st Choice
2st Choice
3st Choice
Conservators for Minor Children:
The person(s) responsible for managing the financial and legal affairs of your minor children in the event that you and your spouse die.
CLIENT #1
1st Choice
2st Choice
3st Choice
CLIENT #2
1st Choice
2st Choice
3st Choice
Danielle M. Shyne, Shyne Law Group, Estate Planning Intake Form
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Caretakers for Pets and Livestock:
The person(s) you would want to take care of your pets or other animals in the event that you and your spouse die
CLIENT #1
1st Choice
2st Choice
3st Choice
CLIENT #2
1st Choice
2st Choice
3st Choice
Disposition of remains/funeral preferences:
PLANNING GOALS:
Please check which of the following issues are important to you:
Type a question
Planning for your incapacity or a disability
Maintaining control over your assets while you are alive
Ensuring that your end of life wishes are respected
Using physician-assisted suicide if you are terminally ill
Avoiding probate
Addressing a conflict with a family member that could affect your estate plan
Protecting your assets from lawsuits or other creditors
Ensuring that your estate plan stays intact in the event you die and your spouse remarries
Providing for your favorite charity after you die
Transferring your business interest(s) before or after you die
Planning for any concerns you may have about your children’s lifestyle, marriage, etc.
Danielle M. Shyne, Shyne Law Group, Estate Planning Intake Form
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ASSET/LIABILITY SUMMARY
(Please list values in U.S. dollars):
ASSETS
CLIENT #1
CLIENT #2
JOINT
Cash accounts and CD’s
Personal effects (cars, jewelry, antiques, etc.)
Securities
Retirement (pension, 401k, IRA)
Life insurance policy
Annuities
Mortgages, notes, other receivables
Partnership or business interest
Oil, gas or mineral interest
Real estate – primary residence
Real estate – other
Other asset
Anticipated inheritance, gifts, etc.
CLIENT #1 TOTAL:
CLIENT #2 TOTAL:
JOINT TOTAL:
LIABILITIES
CLIENT #1
CLIENT #2
JOINT
Loans payable
Accounts payable
Loans against whole life insurance
Automobile loans
Mortgage – primary residence
Mortgage – other real estate
Other liabilities
TOTAL LIABILITIES CLIENT #1
TOTAL LIABILITIES CLIENT #2
TOTAL LIABILITIES JOINT
NET ESTATE
CLIENT #1
CLIENT #2
JOINT
1
Danielle M. Shyne, Shyne Law Group, Estate Planning Intake Form
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DETAILED ASSET/LIABILITY INFORMATION:
REAL PROPERTY
PROPERTY ADDRESS
PRIMARY RESIDENCE?
NAME(S) ON DEED
APPROXIMATE VALUE
1
2
3
4
APPROXIMATE VALUE TOAL:
BANK AND INVESTMENT ACCOUNTS
Type a question
INSTITUTION NAME
ACCOUNT TYPE
NAME(S) ON ACCOUNT
APPROXIMATE BALANCE
1
2
3
4
5
APPROXIMATE BALANCE TOTAL:
PARTNERSHIP, LLC, CORPORATION OR SOLE PROPRIETOR INTERESTS
Type a question
DESCRITION OF INTEREST (PARTNERSHIP, CORPORATION, LLC, etc.)
NAME OF OWNER(S)
APPROXIMATE VALUE
1
2
3
APPROXIMATE VALUE TOTAL:
Danielle M. Shyne, Shyne Law Group, Estate Planning Intake Form
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LIFE INSURANCE, PENSION, IRAs, 401(k)
Type a question
ACCOUNT TYPE
FINANCIAL INSTITUTION
OWNER
DEATH BENEFICIARY
APPROXIMATE VALUE
1
2
3
4
5
APPROXIMATE VALUE TOTAL:
VALUABLE PERSONABLE PROPERTY:
Type a question
DESCRIPTION OF ASSET
NAME OF OWNER
APPROXIMATE VALUE
1
2
3
4
5
APPROXIMATE VALUE TOTAL:
Danielle M. Shyne, Shyne Law Group, Estate Planning Intake Form
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