Intake Form for Will Plans | Rapps & Associates, PLLC

Client Information
Client Legal Name

First NameMiddle NameLast Name
Also Known As/Prefer to be Called
Maiden name (if applicable)
Marital Status
Do you have children?
Number of Children
US Citizen
Date of Birth

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com

	Yes	No
It is okay to communicate with me via my E-mail address

Cell Phone Number
Do you have any of the following?

WillDesignated Standby Guardian for Minor ChildrenTrustPower of AttorneyHealth Care ProxyLiving WillLife InsuranceNone of the above
If you checked yes to any of the above, please provide details and please upload copies of existing documents using the Document Upload Section at the end of this form.
Spouse Information
Spouse Legal Name

First NameMiddle NameLast Name
Former Spouse Name

First NameMiddle NameLast Name
Date of Divorce

MonthDayYear
Date
Deceased Spouse Date of Death

MonthDayYear
Date
Spouse Also Known As/Prefer to be Called
Spouse Maiden name (if applicable)
Spouse US Citizen
Spouse Date of Birth

MonthDayYear
Date
Spouse Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse Email
example@example.com

Spouse Cell Phone Number
Does your spouse have any of the following?

WillDesignated Standby Guardian for Minor ChildrenTrustPower of AttorneyHealth Care ProxyLiving WillLife InsuranceNone of the above
If you checked yes to any of the above, please provide details and please upload copies of existing documents using the Document Upload Section at the end of this form.
Date of Marriage

MonthDayYear
Date
Location of Marriage
Family Information
Are any of your children minors?

YesNo
Child 1 Name

First NameMiddle NameLast Name
Child 1 Date of Birth

MonthDayYear
Date
Child 1 Comments (from a prior marriage; special needs, etc.):
Child 2 Name

First NameMiddle NameLast Name
Child 2 Date of Birth

MonthDayYear
Date
Child 2 Comments (from a prior marriage; special needs, etc.):
Child 3 Name

First NameMiddle NameLast Name
Child 3 Date of Birth

MonthDayYear
Date
Child 3 Comments (from a prior marriage; special needs, etc.):
Child 4 Name

First NameMiddle NameLast Name
Child 4 Date of Birth

MonthDayYear
Date
Child 4 Comments (from a prior marriage; special needs, etc.):
Child 5 Name

First NameMiddle NameLast Name
Child 5 Date of Birth

MonthDayYear
Date
Child 5 Comments (from a prior marriage; special needs, etc.):
Child 6 Name

First NameMiddle NameLast Name
Child 6 Date of Birth

MonthDayYear
Date
Child 6 Comments (from a prior marriage; special needs, etc.):
Child 7 Name

First NameMiddle NameLast Name
Child 7 Date of Birth

MonthDayYear
Date
Child 7 Comments (from a prior marriage; special needs, etc.):Type a question
Child 8 Name

First NameMiddle NameLast Name
Child 8 Date of Birth

MonthDayYear
Date
Child 8 Comments (from a prior marriage; special needs, etc.):
Executor

Client and spouse make their own choices
Client
Executor 1

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Executor 2

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Executor 3

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse
Spouse Executor 1

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse Executor 2

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse Executor 3

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian for Minor Children

Client and spouse should agree
Would you like to name a standby guardian for your minor children?

YesNoWould like to discuss
Standby Guardian 1

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Standby Guardian 2

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Standby Guardian 3

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please add any questions or comments about your standby guardians
Healthcare Proxy

Client and spouse make their own choices
Client
Would you like to name a proxy to make healthcare decisions for you if you are unable?

YesNoWould like to discuss
Healthcare Proxy 1

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like this person to be listed as an emergency contact?
Healthcare Proxy 2

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like this person to be listed as an emergency contact?
Healthcare Proxy 3

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like this person to be listed as an emergency contact?
Please add any questions or comments about your healthcare proxy
Additional health related questions for DocuBank Healthcare Directive Registry Enrollment Form:

*This service is available through Docubank, a 3rd party vendor.
Name of your Physician

PrefixFirst NameMiddle NameLast Name
Specialty
Phone Number
Fax Number
Do you want us to provide your doctor with a copy of your healthcare proxy to have for your file? Please confirm you have provided us with their fax number.

YesNo
Do you have any allergies?

PenicillinSulfaShellfishBee stingsCodeineLatexOther
Do you have any permanent medical condition(s)?

Alzheimer’sLung DiseaseHearing lossStroke historyAsthmaArthritisDiabetesLow visionHeart DiseaseHigh Blood PressureCancer Survivor - Please indicate type in next sectionOther
Any other medical conditions or note for DocuBank card (45 characters max)
Optional Docubank Alerts: Listed emergency contact can receive automated email alerts from DocuBank

They should receive an alert whenever my card is usedThey should receive an email with my member number and PIN when my card becomes active
Spouse
Would your spouse like to name a proxy to make healthcare decisions if they are unable?

YesNoWould like to discuss
Spouse Healthcare Proxy 1

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like this person to be listed as an emergency contact?
Spouse Healthcare Proxy 2

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like this person to be listed as an emergency contact?
Spouse Healthcare Proxy 3

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like this person to be listed as an emergency contact?
Please add any questions or comments about your spouse's healthcare proxy
Spouse - Additional health related questions for DocuBank Healthcare Directive Registry Enrollment Form:

*This service is available through Docubank, a 3rd party vendor.
Spouse Name of your Physician

PrefixFirst NameMiddle NameLast Name
Specialty
Phone Number
Fax Number
Do you want us to provide your doctor with a copy of your healthcare proxy to have for your file? Please confirm you have provided us with their fax number.

YesNo
Do you have any allergies?

PenicillinSulfaShellfishBee stingsCodeineLatexOther
Do you have any permanent medical condition(s)?

Alzheimer’sLung DiseaseHearing lossStroke historyAsthmaArthritisDiabetesLow visionHeart DiseaseHigh Blood PressureCancer Survivor - Please indicate type in next sectionOther
Any other medical conditions or note for DocuBank card (45 characters max)
Optional Docubank Alerts: Listed emergency contact can receive automated email alerts from DocuBank

They should receive an alert whenever my card is usedThey should receive an email with my member number and PIN when my card becomes active
Power of Attorney

Client and spouse make their own choices
Client
Would you like to give an agent power of attorney for financial decisions?

YesNoWould like to discuss
Power of Attorney 1

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Power of Attorney 2

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Power of Attorney 3

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like to specify succession rules for your power of attorney?

YesNoWould like to discuss
Succession rules
Spouse
Would your spouse like to give an agent power of attorney for financial decisions?

YesNoWould like to discuss
Spouse Power of Attorney 1

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse Power of Attorney 2

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse Power of Attorney 3

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would your spouse like to specify succession rules for their power of attorney?

YesNoWould like to discuss
Spouse succession rules
Estate Plan Design

	Yes	No
It is okay to communicate with my spouse via their E-mail address

Please rate the following as to how important they are to you:

	Client	Spouse	Details/Comments
Desire to get affairs in order and create a comprehensive plan to manage affairs in case of death or disability.
Providing for and protecting a spouse.
Providing for and protecting children.
Providing for and protecting children from a previous marriage/relationship.
Providing for and protecting grandchildren.
Disinheriting a family member.
Providing for charities at the time of death.
Plan for the transfer and survival of a family business.
Avoiding or reducing taxes (estate, income, etc.).
Avoiding probate.
Reduce administration costs at time of your death.
Avoiding a conservatorship (“living probate”) in case of a disability.
Avoiding will contests or other disputes upon death.
Protecting assets from lawsuits or creditors.
Preserving the privacy of affairs in case of disability or at time of death from business competitors, predators, dishonest persons and curiosity seekers.
Plan for a child with disabilities or special needs, such as medical or learning disabilities.
Protecting children’s inheritance from the possibility of failed marriages.
Plan for a child with spendthrift concerns and/or drug/alcohol/gambling addictions.
Protect children’s inheritance in the event of a surviving spouse’s remarriage.
Plan for an elderly dependent parent who will require ongoing financial support.
Provide that your death shall not be unnecessarily prolonged by artificial means or measures.
Address concerns that your estate plan is likely to involve disagreement/conflict between family members/beneficiaries?

Please answer the following important questions:

	Client	Spouse	Details/Comments
Are you (or your spouse) receiving Social Security, disability, or other governmental benefits? Describe in comments.
Are you (or your spouse) making payments pursuant to a divorce or property settlement order? Please upload a copy below.
If married, have you and your spouse signed a pre- or post-marriage contract? Please upload a copy below.
Have you (or your spouse) been widowed? If a federal estate tax return or a state death tax return was filed, please upload a copy below.
Have you (or your spouse) ever filed federal or state gift tax returns? Please upload copies of these returns.
Do you support any charitable organizations now that you wish to make provisions for at the time of your death? If so, please explain in the comments.
Are there any other charitable organizations you wish to make provisions for at the time of your death? If so, please explain in the comments.
If married, have you lived in any of the following states while married to each other? Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, or Wisconsin.
Are you (or your spouse) currently the beneficiary of anyone else’s trust? If yes, please explain in the comments.
Do any of your children have special educational, medical, or physical needs?
Do any of your children receive governmental support or benefits?
Do you provide primary or other major financial support to adult children or others?
Are there beneficiaries you specifically want to leave out of your estate plan? Are you aware of the potential consequences of doing so?
Do you get along with each of your children's partners?
Do you intend to give certain assets to specific beneficiaries?
Does your spouse/children/executor know your intended estate provisions?

Estimated Net Worth
How and to whom do you want your assets distributed at death? Do not be concerned with the "legalisms", just explain how you wish the property to be distributed and who should receive the property.
Any additional relevant information.
Document Upload Section
Upload documents including photo ID, financial documents, etc.

Cancelof
Should be Empty:

Client Information

Spouse Information

Family Information

Executor

Client

Spouse

Guardian for Minor Children

Healthcare Proxy

Client

Spouse

Power of Attorney

Client

Spouse

Estate Plan Design

Document Upload Section