Estate Planning Client Intake Form

Client's Name:

Spouse's Name:

Street Address:

Mailing Address (if different):

County of Residence:

Home Telephone Number:

Work Phone Number:

Cellular:

Email:

Preferred Contact Method:

Client Date of Birth:

Spouse Date of Birth:

Country of Citizenship (Client):

Country of Citizenship (Spouse):

Date of Marriage:

Marital Status (If Not Married):

Any previous marriages?

If so, please provide the names of prior spouses, starting/ending dates of marriage, and disposition of marriage (divorce, death, etc).

Have you lived in Alaska, Wisconsin, Arizona, California, Idaho, Louisiana, New Mexico, Texas or Washington? If so, list dates of residence for those states.

Do you have a current Will, Trust, or other estate planning documents? If so, bring original documents to appointment

Children of Your Current Marriage (include living and deceased; names, marriage status, dates of birth):

Number and Age of Grandchildren:

Children of Any Previous Marriages (include living and deceased; names, marriage status, dates of birth):

Number and Age of Grandchildren

List Siblings, Parents, and Other Living Family Members:

Do any family members suffer a disability?

If so, who?

Where does he/she live?

Is he/she capable of working?

Does he/she have a monthly income?

If he/she receives benefits, indicate what type: SSI SSDI AHH Medicaid Medicare

Real Property (Address, Name owning property, Fair Market Value, Mortgage)

Stocks, Bonds, and Securities (Description, Number of Shares, Name Shares Held, Fair Market Value, Basis)

Life Insurance Policies:

Name of Company:

Name of Insured:

Beneficiary(ies):

Whole or Term?

Amount:

Cash Value:

Retirement Plans:

Owner:

Type and Company or Location:

Benefit/Value:

Beneficiary(ies):

Bank Accounts:

Type and Account Number:

Bank or Credit Union Name:

Beneficiary(ies):

Value:

Any other significant assets? Examples include jewelry, fine art, classic cars, or valuable collections. List and state approximate value.

Do you have a safety deposit box? Indicate the location, contents, and approximate value of contents.

Are you expecting an inheritance?

Are there any family members you specifically wish to disinherit?

Are there any disabled family members you wish provided for in the event of your death?

Do you have any specific designations of property, e.g. an item of value you want passed on to a particular person?

Do you have an idea who you wish to administer your estate? If so, indicate the name, address, telephone number, email, and relationship.

Is there a charity or non-family member you wish to benefit from your estate?

If you have minor children, do you have a preference for their guardian? If so, indicate name, address, telephone number, email, and relationship.