Rothwell Notary Personal Planning Client Intake Form

Rothwell Notary Corporation
#101-554 Leon Ave Kelowna, BC V1Y 6J6

Phone: 250.861.4452 Fax: 778.478.6391

info@RothwellNotary.com

www.RothwellNotary.com
Client Intake Form

Personal Planning (Wills / Powers of Attorney / Representation Agreements)
Your information
Title/Prefix
Full Legal Name

First NameMiddle NamesLast Name
A.k.a
Birthdate

MonthDayYear
Date
Place of Birth
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone # (Home)

Area CodePhone Number
Phone # (Cell)

Area CodePhone Number
Occupation
E-Mail Address
example@example.com
Employer
Marital Status
Date of Marriage

MonthDayYear
Date
Prior Marriage(s)
Canadian Citizen
Registered Indian
Spouse
Title/Prefix
Full Legal Name

First NameMiddle NamesLast Name
A.k.a
Birthdate

MonthDayYear
Date
Place of Birth
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone # (Home)

Area CodePhone Number
Phone # (Cell)

Area CodePhone Number
Occupation
E-Mail Address
example@example.com
Employer
Date of Marriage

MonthDayYear
Date
Marital Status
Canadian Citizen
Prior Marriage(s)
Registered Indian
Please identify any other items you may feel are pertinent. For instance if you are the legal guardian of a person under age 19 or if you are responsible for care of an adult (elderly, incapacitated or disabled) or if you have been named the Executor for anyone who is still living.
Child # 1
Full Legal Name

First NameMiddle NamesLast Name
Birthdate

MonthDayYear
Date
City
Province
Postal Code
Phone # (h)
Format: (000) 000-0000.
Phone # (c)
Format: (000) 000-0000.
Occupation
Marital Status
Grandchild
Grandchild
Grandchild
Child # 2
Full Legal Name

First NameMiddle NamesLast Name
Birthdate

MonthDayYear
Date
City
Province
Postal Code
Phone # (h)
Format: (000) 000-0000.
Phone # (c)
Format: (000) 000-0000.
Occupation
Marital Status
Grandchild
Grandchild
Grandchild
Grandchild
Child # 3
Full Legal Name

First NameMiddle NamesLast Name
Birthdate

MonthDayYear
Date
City
Province
Postal Code
Phone # (h)
Format: (000) 000-0000.
Phone # (c)
Format: (000) 000-0000.
Occupation
Marital Status
Grandchild
Grandchild
Grandchild
Grandchild
Child # 4
Full Legal Name

First NameMiddle NamesLast Name
Birthdate

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Province
Postal Code
Phone # (h)
Format: (000) 000-0000.
Phone # (c)
Format: (000) 000-0000.
Occupation
Marital Status
Grandchild
Grandchild
Grandchild
Grandchild
Child # 5
Full Legal Name

First NameMiddle NamesLast Name
Birthdate

MonthDayYear
Date
City
Province
Postal Code
Phone # (h)
Format: (000) 000-0000.
Phone # (c)
Format: (000) 000-0000.
Occupation
Marital Status
Grandchild
Grandchild
Grandchild
Grandchild
Child # 6
Full Legal Name

First NameMiddle NamesLast Name
Birthdate

MonthDayYear
Date
City
Province
Postal Code
Phone # (h)
Format: (000) 000-0000.
Phone # (c)
Format: (000) 000-0000.
Occupation
Marital Status
Grandchild
Grandchild
Grandchild
Grandchild
Should be Empty:

Rothwell Notary Corporation

Client Intake Form

Your information

Spouse

Child # 1

Child # 2

Child # 3

Child # 4

Child # 5

Child # 6