Standard Estate Planning Intake Form

Standard Estate Planning Intake Form

Pro Bono Unit Wills and Advance Directives Clinics
**PLEASE REVIEW THE FOLLOWING PRIOR TO COMPLETING THIS FORM**

Completition of this form does not guarantee that free will/advance directive services will be provided to you.

This form will be reviewed by JALA staff to prescreen you for this legal service and potential placement with a pro bono attorney. If you qualify (including meeting certain financial qualifications), you will receive an email from our office.

Please note that Jacksonville Area Legal Aid does not accept cases for Trusts. If you have questions about creating a Trust, please contact a private attorney.

If you have questions prior to completing this form, please email Stacey DeLuca, Director of Pro Bono, at Stacey.DeLuca@jaxlegalaid.org.

Updated 7/23/2025; 9/13/2025 - AJI
Date

MonthDayYear
Full Name

First NameMiddle NameLast Name
Preferred Name (if different from the above)

First NameMiddle NameLast Name
Mailing Address

Street Address (including apartment or unit number)

City

CountyState

Zip Code
Is the above address the same address where you reside?
If not, where do you reside?

Street Address (including apartment or unit number)

City

CountyState

Zip Code
Phone (best number for contact)
Format: (000) 000-0000.
Can we text you at this number?
Safe and Confidential Email Address
example@example.com
Birth Date

MonthDayYear
Age
Last 4 of SSN
Gender/Gender Identity
Citizenship Status
Ethnicity

Other
Race

Other
Marital Status

Other
Veteran/Military Status

If Retired/Discharged, please check the box and list your discharge date.
Have you ever applied to JALA before?
If yes, when?
Income and Asset Verification

**Jacksonville Area Legal Aid uses this information for grant qualifying purposes. This information is not disclosed to anyone except legal aid. Estimated amounts are permissible.
Are you currently employed?
If Yes, where are you currently employed?
What is your Gross Monthly Income?
Income before taxes and other withholdings.
Do you have other sources of income? If so, from where or from whom?
This includes income from other people residing in your home (e.g. spouse or adult child)
What is the total Gross Monthly Income from this other source?
Income before taxes and other withholdings.
Number of adults, including yourself, residing in your home:
Total number of minors (under 18) residing in your home.
Real Estate (Primary Residence) Value
Applicable only if you own (not rent) a home.
Value of Other Real Estate
If none, enter 0.00
Value of Primary Vehicle
If none, enter 0.00
Value of Secondary Vehicle
If none, enter 0.00
Value of Other Vehicles
Example: other cars, motorcycles, boats. If none, enter 0.00
Monthly Mortgage or Rent Amount
Include first and second mortgages
Value of Retirement Account
If none, enter 0.00
Checking Account Value
If none, enter 0.00
Savings Account Value
If none, enter 0.00
Value of any other accounts
If none, enter 0.00
Will Questionnaire

Complete if you would like a Last Will and Testament ("Will"). ***NOTE: It is ok if you do not know how to answer the question(s), as an attorney will consult with you.
Do you currently have a Will?
Can you sign a Will yourself?
Confirmation of Marital Status:
If you are Married/Partnered, will your spouse/partner be creating a Will with you?
Spouse's/Partner's Name:First Name   Last Name  Age:   Age
Address:   Street Address   Address Line 2   City   State   Zip
Telephone Number:   Area Code   Phone Number
Email Address:   Email   Date of BirthDOB   Last 4 of SSN:Last 4 only
Do you have Children?
Child #1 Name:   First Name   Last Name  Age:   Age
Address:   Street Address   Address Line 2   City   State   Zip
Telephone Number:   Area Code   Phone Number
Will This Child Inherit?   Yes   No
Child #2 Name:   First Name   Last Name  Age:   Age
Address:   Street Address   Address Line 2   City   State   Zip
Telephone Number:   Area Code   Phone Number
Will This Child Inherit?   Yes   No
Child #3 Name:   First Name   Last Name  Age:   Age
Address:   Street Address   Address Line 2   City   State   Zip
Telephone Number:   Area Code   Phone Number
Will This Child Inherit?   Yes   No
Child #4 Name:   First Name   Last Name  Age:   Age
Address:   Street Address   Address Line 2   City   State   Zip
Telephone Number:   Area Code   Phone Number
Will This Child Inherit?   Yes   No
Child #5 Name:   First Name   Last Name  Age:   Age
Address:   Street Address   Address Line 2   City   State   Zip
Telephone Number:   Area Code   Phone Number
Will This Child Inherit?   Yes   No
If any of your Children have passed away, please list their name(s) and indicate if they had any children of their own:
To whom do you want your property to go to upon your passing? ***Choose the option below that best suits your wishes:

Other
Assets: Listing your assets will help an attorney better understand how to draft your Will and how best to advise you regarding your assets. An Attorney may also talk to you about a Ladybird Deed. ***Check all that apply.

Other
Personal Representative Designation: You must include in your Will the name(s) of the person(s) you wish to serve as the personal representative (aka "executor") of your estate. A Personal Representative is the "manager" of the estate who carries out the terms of your will. They may, but do not have to be, beneficiaries of your estate.
- If your personal representative resides outside of the State of Florida, he/she/they must be a blood-relative.
- It is good practice to have a "Primary" Designated Person and an alternate.
Personal Representative:  First Name   Last Name  Age:
Address:   Street Address   Address Line 2   City   State   Zip
Telephone Number:   Area Code   Phone Number
Alternative Personal Representative:  First Name   Last Name  Age:
Address:   Street Address   Address Line 2   City   State   Zip
Telephone Number:   Area Code   Phone Number
Advance Directives Questionnaire

Complete if you would like your Advance Directives drafted (Power of Attorney, Health Care Surrogate, Living Will, and Designation Naming Pre Need Guardian) ***NOTE: It is ok if you do not know how to answer the question(s), as an attorney will consult with you.
- Durable Power of Attorney (“POA”): This document allows you to name another person to act on your behalf. This means that the person(s) you list may make decisions on your behalf (example: make banking decisions or obtain medical documents).
  - You are still able to make decisions yourself as long as you are not incapacitated.
  - This document is valid once signed and is valid even if you are incapacitated.
  - The document only ceases to exist if (a) you pass away, (b) you revoke the document (in writing), (c) you destroy all copies of the document including the original, or (d) you amend the document.
  - It is good practice to have a "Primary" Designated Person and an alternate. You may also have more than one alternate.
First (Primary) Designated Person's Name, Address, and Phone Number:
Alternative (Backup) Person's Name, Address, and Phone Number:
If you do NOT Have a Backup, skip or list N/A
Third (Backup) Designated Person's Name, Address, and Phone Number:
If you do NOT have a Third Backup, skip or list N/A
- Health Care Surrogate Designation: This document allows you to name another person to make medical decisions on their behalf. This is very important, especially if you are not married or if your spouse is unable to act on your behalf.
  - You are still able to make decisions yourself as long as you are not incapacitated.
  - Your designees also have authority to carry out the terms of your Living Will.
  - It is good practice to have a "Primary" Designated Person and an alternate. You may also have more than one alternate.
First (Primary) Designated Person's Name, Address, and Phone Number:
If the same as the POA, type SAME
Second (Backup) Designated Person's Name, Address, and Phone Number:
If the same as the POA, type SAME. If you do NOT have a Backup, skip or list N/A
Third (Backup) Designated Person's Name, Address, and Phone Number:
If the same as the POA, type SAME. If you do NOT have a Third Backup, skip or list N/A
- Living Will: This document is made in appreciation that death is as much a part of life as is living. This document allows a person to name another to carry out your last wishes, so that life-prolonging procedures are not used when death is imminent.
  - Examples of life-prolonging procedures include: life-support treatment; medical devices put in to help me breathe; food and water supplied by medical device (tube feeding); cardiopulmonary resuscitation (CPR); major surgery; blood transfusions; dialysis; antibiotics; and anything else meant to keep me alive.
  - In other words, this is a right to die document which is very important, especially if you are not married or if your spouse is unable to act on your behalf.
  - The designees listed in your Health Health Care Surrogate Designation likewise have authority to carry out the terms of your Living Will.
- Pre-Need Guardian Designation: Although the above documents will hopefully eliminate the need for a court supervised guardian, certain circumstances may require the appointment of a legal guardian. This document will indicate your preference for the court appointment.
  - It is good practice to have a "Primary" Designated Person and an alternate. You may also have more than one alternate.
First (Primary) Designated Person's Name, Address, and Phone Number:
If the same as the POA/HCS, type SAME
Second (Backup) Designated Person's Name, Address, and Phone Number:
If the same as the POA/HCS, type SAME. If you do NOT have a Back-up, skip or list N/A
Third (Backup) Designated Person's Name, Address, and Phone Number:
If the same as the POA/HCS, type SAME. If you do NOT have a Third Back-up, skip or list N/A
Is there anything else that you would like the Attorney to know about your Estate Planning wishes?

0/500
PARTICIPANT VERIFICATION
By using this form, you agree that the information in this tool is not a substitute for legal advice. Jacksonville Area Legal Aid, Inc. (JALA) will use the information you provide to determine if we can help you. Providing your information or applying for services does not mean that you are our client and does not create an attorney-client relationship unless a separate Retainer Agreement is signed by me and JALA. Any legal assistance provided in today's session will be free of charge. The information that I have provided in this form is true and complete.
Should be Empty:

Income and Asset Verification

Will Questionnaire

Advance Directives Questionnaire

PARTICIPANT VERIFICATION