Estate Planning Intake Form

Estate Planning Intake Form
Personal Information
Your Full Name
Your Spouse’s Full Name
Primary Residence
Your Telephone Number
Please enter a valid phone number.
Children Information
Do you have children?

YesNo
How many Children?

12345678More than 8
Name: Age: Date of Birth:
Name: Age: Date of Birth:
Name: Age: Date of Birth:
Name: Age: Date of Birth:
Name: Age: Date of Birth:
Name: Age: Date of Birth:
Name: Age: Date of Birth:
Name: Age: Date of Birth:
Do you have any children that you want to disinherit?
Real Property Ownership
Do you own any other real property?

YesNo
Provide the address:
Attach a copy of the most current deed for all real property

Attach a copy of the most current deed showing the legal description and how title is currently held (i.e. tenants in common, joint tenancy).
Cancelof
Estate plans are generally established to divide your estate equally among your beneficiaries. If this is acceptable, please initial:
Special Gifts of Personal Property
Do you have any special gifts of your personal property you would like to give to family members upon your passing?

YesNo
List any special gifts:
Bank Accounts and Trust Funding:

Do you want your bank accounts to be included in the trust? If you want to fund your trust with your bank accounts you will have to re-title the accounts. For example: Jane Doe as trustee of the Doe family trust dated 12/12/2021. If not, I can provide a general letter to be given to your financial institutions to instruct them to handle this for you.
Provide your wishes in the following space.
Provide your wishes
Distribution of Assets Upon Death
Who would you like to be named as the first person in charge of distributing your assets upon your death?
Person 1
This person shall serve first unless they die before you or decline to act
Person 2
This person shall serve second if the person in number 1. is unable or declines to act
Person 3
If you have a third person in mind if numbers 1 & 2 are unavailable please list them here
INSTRUCTIONS FOR HEALTH CARE
End-of-Life Decisions:

Choice Not To Prolong LifeChoice To Prolong Life
Choice Not to Prolong Life:

I have an incurable and irreversible condition that will result in my death within a relatively short timeI become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousnessthe likely risks and burdens of treatment would outweigh the expected benefits,If the extension of my life would result in a mere biological existence, devoid of cognitive function, with no reasonable hope for normal functioning, then I do not desire any form of life sustaining procedures, including nutrition and hydration unless necessary for my comfort or alleviation of pain or, if life sustaining treatment has been instituted, I desire that it be withdrawn. It is my desire that my agent consider relief from suffering, preservation or restoration of functioning, and the quality as well as extent of the life being preserved when decisions are made concerning life sustaining care, treatment, services, and procedures. In making the decision to withhold or remove treatment, my agent should ask the question: "Is the proposed treatment an aid to recovery or merely a prolongation of inevitable death?" What is "reasonable," what is "an aid to recovery," and what is "merely a prolongation of inevitable death" shall be determined by my agent after consulting with my attending physicians.
Choice to Prolong Life:

I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.
Relief From Pain:

YesNo
Other Wishes:
Provide any specific instructions here such as a “celebration of life to be held at”.
Medical Decision Makers
Who would you like to place in charge of your medical?
Person 1
This person shall serve first unless they die before you or decline to act
Person 2
This person shall serve second if the person in number 1. is unable or declines to act
Person 3
If you have a third person in mind if numbers 1 & 2 are unavailable please list them here
Disposition of Remains
My body shall be:

CrematedBuried
I have previously made arrangements through:
Background History
Have you ever been married before?

YesNo
How did this marriage end?

DivorceDeathNullity
Date of death or date of judgment for divorce or nullity:
Do you have any children that have passed away?

YesNo
Did your child who passed away leave behind any children of their own?

YesNo
What are their names, ages and birth dates?
Press "Enter" to start a new line.
Any other marriages?

YesNo
How did this marriage end

DeathDivorceNullity
Do you currently have children? If so, please provide their names and date of birth in the following space.
Press "Enter" to start another line.
Do you have any step children? If so, do you want them to inherit in the same manner as if you had adopted them as your own children?
Press "Enter" to start another line.
Please list any additional information you would like me to know.
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Single
$599

Married Couple
$699

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Estate Planning Intake Form

Personal Information

Children Information

Real Property Ownership

Special Gifts of Personal Property

Bank Accounts and Trust Funding:

Distribution of Assets Upon Death

INSTRUCTIONS FOR HEALTH CARE

Medical Decision Makers

Disposition of Remains

Background History