ESTATE PLANNING STAGE 1
Client Information Intake Form
CLIENT'S GENERAL INFORMATION
SPOUSE'S NAME AND GENERAL INFORMATION WILL APPEAR ON THE NEXT PAGE.
CLIENT'S NAME
*
First Name
Last Name
GENDER
*
Male
Female
DATE OF BIRTH
-
Month
-
Day
Year
Date
SSN
MARITAL STATUS
Please Select
MARRIED
SINGLE
DIVORCED
WIDOWED
DATE OF MARRIAGE
-
Month
-
Day
Year
Date
EMPLOYMENT STATUS
Please Select
EMPLOYED
UNEMPLOYED
SELF EMPLOYED
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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SPOUSE'S GENERAL INFORMATION
PLEASE COMPLETE THIS INFORMATION TO THE BEST OF OUR ABILITY
SPOUSE'S NAME
First Name
Last Name
GENDER
Male
Female
DATE OF BIRTH
-
Month
-
Day
Year
Date
SSN
MARITAL STATUS
Please Select
MARRIED
SINGLE
DIVORCED
WIDOWED
DATE OF MARRIAGE
-
Month
-
Day
Year
Date
EMPLOYMENT STATUS
Please Select
EMPLOYED
UNEMPLOYED
SELF EMPLOYED
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
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1 DECENDENT/BENEFICIARY'S GENERAL INFORMAITON
First Name
Last Name
GENDER
Male
Female
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
2 DECENDENT/BENEFICIARY'S GENERAL INFORMAITON
First Name
Last Name
GENDER
Male
Female
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
3 DECENDENT/BENEFICIARY'S GENERAL INFORMAITON
First Name
Last Name
GENDER
Male
Female
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
4 DECENDENT/BENEFICIARY'S GENERAL INFORMAITON
First Name
Last Name
GENDER
Male
Female
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
5 DECENDENT/BENEFICIARY'S GENERAL INFORMAITON
First Name
Last Name
GENDER
Male
Female
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Next
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PR/POA/TTE
Please use the spaceing below to write ALL the names of your Personal Representatives/ Power Of Attorneys/ Trustees
CLIENT'S Personal Representative
CLIENT'S Power of Attorney
CLIENT'S Trustee
SPOUSE'S Personal Representative
SPOUSE'S Power of Attorney
SPOUSE'S Trustee
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BUSINESS / LLC INFORMATION
BUSINESS AND/OR LLC NAME:
MANAGER NAME(S):
BUSINESS AND/OR LLC ADDRESS:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
OPERATING AGREEMENT SIGNING DATE:
-
Month
-
Day
Year
Date
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PROPERTY
PLEASE COMPLETE INFORMATION REGARDING PROPERTY YOU OWN
DO YOU OWN ANY PROPERTY? IF SO, WHAT IS THE ADDRESS:
DO YOU HAVE THE DEEDS FOR THIS PROPERTY?
Please Select
YES
NO
NOT SURE WHAT I HAVE
WHAT TYPE OF FINANCIAL ACCOUNTS DO YOU HAVE (checking, savings, retirement, brokerage etc.)
CHECKING
SAVINGS
BROKERAGE
RETIREMENT
Other
P.R. Curtman Investments LLC
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Should be Empty: