ESTATE PLANNING INTAKE FORM

Your Information
Full Legal Name

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth

MonthDayYear
Other names used (and nicknames):
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell
Please enter a valid phone number.
Personal E-Mail Address
example@example.com
Marital Status
If Married, Date of Marriage:

MonthDayYear

Spouse/Partner Information
Full Name

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth

MonthDayYear
Other Names Used (and Nicknames)
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell
Please enter a valid phone number.
Personal e-Mail
example@example.com

Prior Marriage Information
Prior Spouse Name

PrefixFirst NameMiddle NameLast NameSuffix
How Marriage Ended (i.e. death, divorce)
Date of Marriage

MonthDayYear
Date of Death or Divorce

MonthDayYear
Prior Spouse Name

PrefixFirst NameMiddle NameLast NameSuffix
How Marriage Ended (i.e. death, divorce)
Date of Marriage

MonthDayYear
Date of Death or Divorce

MonthDayYear

Children
Child 1 - Full Legal Name

First NameMiddle NameLast NameSuffix
Please select one:

Child of both spousesChild of Client 1Child of Client 2
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate

MonthDayYear
Date
Special Concerns
Child 2 - Full Legal Name

First NameMiddle NameLast NameSuffix
Please select one:

Child of both spousesChild of Client 1Child of Client 2
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate

MonthDayYear
Date
Special Concerns
Child 3 - Full Legal Name

First NameMiddle NameLast NameSuffix
Please select one:

Child of both spousesChild of Client 1Child of Client 2
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate

MonthDayYear
Date
Special Concerns

Additional Relevant Information
Please provide any additional information which may be relevant:

Burial Instructions
Please state any burial/cremation instructions (if any):

Advisors
Accountant's Name

First NameLast NameSuffix
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Financial Advisor's Name

First NameLast NameSuffix
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Life Insurance Agent's Name

First NameLast NameSuffix
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Guardian for Person and Estate of Minor Children
The guardian you name for your minor children will have responsibility for the care of your children upon your death. If you decide to choose a married couple as co-guardians, you may wish to include a provision for a change in guardianship if the couple divorces.
1. Initial Guardian's Name

PrefixFirst NameMiddle NameLast NameSuffix
Phone Number
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. First Successor Guardian's Name

PrefixFirst NameMiddle NameLast NameSuffix
Phone Number
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Second Successor Guardian's Name:

PrefixFirst NameMiddle NameLast NameSuffix
Phone Number
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Agents-in-Fact for Power of Attorney for Healthcare
The agent you name under your power of attorney for health care will have authority to make decisions regarding your medical treatment and care, should you become unable to make these decisions yourself.
CLIENT 1 AGENTS (in order of preference)
1. Full Name

PrefixFirst NameMiddle NameLast NameSuffix
Phone Number
Relationship to you
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Full Name

PrefixFirst NameMiddle NameLast NameSuffix
Phone Number
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Full Name

First NameMiddle NameLast NameSuffix
Phone Number
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CLIENT 2 AGENTS (in order of preference)
1. Full name

PrefixFirst NameMiddle NameLast NameSuffix
Phone Number
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Full Name

PrefixFirst NameMiddle NameLast NameSuffix
Phone Number
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Full Name

PrefixFirst NameMiddle NameLast NameSuffix
Phone Number
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Agents-in-Fact for Power of Attorney for Property
The agent you name under your power of attorney for property will have authority to make decisions regarding your property. You may omit any addresses that you have already supplied.
CLIENT 1 AGENTS (in order of preference)
1. Full Name

PrefixFirst NameMiddle NameLast NameSuffix
Phone Number
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Full Name

PrefixFirst NameMiddle NameLast NameSuffix
Phone Number
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Full Name

PrefixFirst NameMiddle NameLast NameSuffix
Phone Number
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CLIENT 2 AGENTS (in order of preference)
1. Full Name

First NameMiddle NameLast NameSuffix
Phone Number
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Full Name

PrefixFirst NameLast NameSuffix
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Full Name

PrefixFirst NameMiddle NameLast NameSuffix
Phone Number
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Fiduciaries: Executor and/or Trustee
Your executor and/or trustee will be in charge of financial matters pursuant to your instructions upon your death, or during your lifetime under a living trust if you become disabled.
CLIENT 1 AGENTS (in order of preference)
1. Full Name

PrefixFirst NameMiddle NameLast NameSuffix
Phone Number
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Full Name

PrefixFirst NameMiddle NameLast NameSuffix
Phone Number
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Full Name

PrefixFirst NameMiddle NameLast NameSuffix
Phone Number
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CLIENT 2 AGENTS (in order of preference)
1. Full Name

PrefixFirst NameMiddle NameLast NameSuffix
Phone Number
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Full Name

PrefixFirst NameMiddle NameLast NameSuffix
Phone Number
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Full Name

PrefixFirst NameMiddle NameLast NameSuffix
Phone Number
Relationship to you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Special Provisions
Please list any special provision: (e.g., beneficiary with disability, immediate relative who you want to disinherit):

Disposition Intent
Please indicate how you want your estate distributed at your death, including any specific bequests:
If you have expressed an intent above to distribute any of your estate (e.g., specific bequests to individuals and/or charitable organizations) to persons or organizations who are not already described above, please list below their full name, address, telephone number and relation to you (e.g., sister, friend, cousin, etc.):

Personal Financial Information
Please list the approximate value of all of your assets, including the following:

	Owned by Client 1	Owned by Client 2	Owned Jointly
Cash (bank accounts, certificates of deposit
Securities (stocks, bonds, mutual fund)
Notes & Receivables (money owed to you)
Home Value
Other Real Estate Value
Husband's Life Insurance
Wife's Life Insurance
IRAs, 401(k) Accounts
Other Retirement Plans (death benefit)
Annuities
Antiques & Collectibles
Other Personal Property (cars, jewelry, boat, etc.)
Anticipated Gifts & Inheritances
Other Assets
TOTAL ASSETS

	Owned by Client 1	Owned by Client 2	Owned Jointly
Home Mortgage
Mortgage on Other Real Estate
Loans Against Life Insurance
Other Debts, Claims, Liens & Judgments
TOTAL LIABILITIES

Net Worth (Assets-Liabilities=Net Worth)

	Owned by Client 1	Owned by Client 2	Owned Jointly
Net Worth

Combined Approximate Net Worth (Add all Net Worth values together)

Additional Items Relevant to Estate Planning
Please let us review copies of signed documents which you have, including, for example (please check off all documents that apply):

Net Worth (Assets-Liabilities=Net Worth)

	Client 1	Client 2
Will
Trust
Title Insurance Policy, Recent Real Estate Tax Bill & Recorded Deed for Real Estate
Irrevocable Life Insurance Trust ("ILIT")
Power of Attorney for Property
Power of Attorney for Health Care
Living Will
Gift Tax Returns
Pre-Marital or Post-Marital Agreements
Buy/Sell Agreements
Partnership Agreements

Please Upload the Documents Identified in the Table Above

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