Estate Planning Form

How did you hear about Bertsch & Boze Elder Law, PC?

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Alternate Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Date of Birth

Are you married?

YesNo

If Yes, please provide information for your Spouse below:

Name of Spouse

First NameLast Name

Address (If different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Alternate Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Date of Birth

Have you or your Spouse been married previously?

YesNo

Do you or your spouse have children from a previous relationship?

YesNo

How many children

(If none, skip to the next section. If more than five children contine on another sheet)

Child 1 Name

First NameLast Name

Relationship

Child of ClientChild of SpouseChild of Both

Date of Birth

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Child 2 Name

First NameLast Name

Relationship

Child of ClientChild of SpouseChild of Both

Date of Birth

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Child 3 Name

First NameLast Name

Relationship

Child of ClientChild of SpouseChild of Both

Date of Birth

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Child 4 Name

First NameLast Name

Relationship

Child of ClientChild of SpouseChild of Both

Date of Birth

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Child 5 Name

First NameLast Name

Relationship

Child of ClientChild of SpouseChild of Both

Date of Birth

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Do any of your children have Supplemental Needs and are receiving or may need to receive benefits in the future?

YesNo

If yes, Which Benefits?

Besides spouse and children, who are other trusted people in your life that you may want to make important decisions for you if you were unable to make them for yourself? If you do not have or cannot think of anyone, DON'T WORRY, just leave blank.

A Supplemental Needs Trust is for someone with a disability, receiving SSI, Medicaid or other government benefits. This trust allows them to receive money or property without losing their eligibility for these benefits.

Person 1 Name

First NameLast Name

What is their relationship to Client and/or Spouse? (ie, cousin, neighbor, friend, etc.)

Family MemberFriendOther

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Person 2 Name

First NameLast Name

What is their relationship to Client and/or Spouse? (ie, cousin, neighbor, friend, etc.)

Family MemberFriendOther

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Person 3 Name

First NameLast Name

What is their relationship to Client and/or Spouse? (ie, cousin, neighbor, friend, etc.)

Family MemberFriendOther

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Are there any person(s) in your life that you specifically DO NOT want handling important decisions for you?

If so, please name them below.

In general terms, how do you want your assets to be distributed after your death? This does not need to be highly specific, we just want a sense of your ultimate goals and wishes?

All to spouse and then to childrenAll to spouse and then to (fill out below)I'm not sure and I need help with these decisionsAll to childrenOther (fill out below)

All to the Spouse and then to:

Other:

Please include any other information you feel we should know:

In order for the attorney to fully evaluate your situation and give you the best possible advice, we ask thet you comlete (in general tems) the Financial Asset Worksheeet below, keeping in mind that all information you provide to us is always held in the strictest confidence and never shared without your consent.

Real Estate Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Ownership

ClientSpouseJoint

Approximate Value

US Dollars

Real Estate Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Ownership

ClientSpouseJoint

Approximate Value

US Dollars

Real Estate Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Ownership

ClientSpouseJoint

Approximate Value

US Dollars

BANKING

Vehicle 1

Vehicle 2

Vehicle 3

INVESTMENTS

RETIREMENT/IRAs

Life Insurance Policies

If you have out of state assets specifically real estate, mineral rights, etc., be sure to bring them to attorney's attention during your meeting.

Approximate Total Value of Estate $

US Dollars