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

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

Cell Phone Number
Format: (000) 000-0000.
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
Format: (000) 000-0000.
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
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
Format: (000) 000-0000.
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
Format: (000) 000-0000.
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
Format: (000) 000-0000.
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
Format: (000) 000-0000.
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
Format: (000) 000-0000.
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
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Trustee

Client and spouse make their own choices
Client
Trustee 1

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Trustee 2

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Trustee 3

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Specify instructions for trustee/co-trustee administration and succession
Spouse
Spouse Trustee 1

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse Trustee 2

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse Trustee 3

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse - Specify instructions for trustee/co-trustee administration and succession
Guardian for Minor Children

Client and spouse should agree
YesNoWould like to discuss
Standby Guardian 1

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Format: (000) 000-0000.
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
Format: (000) 000-0000.
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
Format: (000) 000-0000.
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
YesNoWould like to discuss
Healthcare Proxy 1

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Format: (000) 000-0000.
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
Format: (000) 000-0000.
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
Format: (000) 000-0000.
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
Format: (000) 000-0000.
Fax Number
Format: (000) 000-0000.
YesNo
PenicillinSulfaShellfishBee stingsCodeineLatexOther
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)
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
YesNoWould like to discuss
Spouse Healthcare Proxy 1

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Format: (000) 000-0000.
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
Format: (000) 000-0000.
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
Format: (000) 000-0000.
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
Format: (000) 000-0000.
Fax Number
Format: (000) 000-0000.
YesNo
PenicillinSulfaShellfishBee stingsCodeineLatexOther
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)
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
YesNoWould like to discuss
Power of Attorney 1

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Format: (000) 000-0000.
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
Format: (000) 000-0000.
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
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNoWould like to discuss
Succession rules
Spouse
YesNoWould like to discuss
Spouse Power of Attorney 1

First NameMiddle NameLast Name
Relationship
Email
example@example.com
Phone Number
Format: (000) 000-0000.
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
Format: (000) 000-0000.
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
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNoWould like to discuss
Spouse succession rules
Other Information
Estimated Net Worth
Any additional relevant information
Document Upload Section
Upload documents including photo ID, financial documents, etc.

Cancelof
Should be Empty:

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

Client Information

Spouse Information

Family Information

Executor

Client

Spouse

Trustee

Client

Spouse

Guardian for Minor Children

Healthcare Proxy

Client

Spouse

Power of Attorney

Client

Spouse

Other Information

Document Upload Section