U.S. citizen?

Yes

No

Marital Status

Married

Separated

Divorced

Widowed

Single

Domestic Partnership

If married or separated, spouse's name:

Spouse's date of birth

Spouse's email:

Spouse's phone number:

Spouse's address, if different:

U.S. citizen?

Yes

No

Date of Marriage

Have you or your spouse completed previous wills, trust, power of appointment or other estate planning?

Yes

Please attach existing documents.

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No

Have you ever filed a gift tax return?

Yes

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No

Are you a party to a pre- or post-nuptial agreement, divorce decree, or marital agreement?

Yes

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No

Are you or your spouse currently the beneficiary of anyone else’s trust?

Yes

No

Have any of your children predeceased you?

Yes

No

Do any of your relatives have special education, medical, or physical needs?

Yes

No

Do any of your relatives receive governmental support or benefits?

Yes

No

Are you or your spouse receiving social security, disability, or other governmental benefits?

Yes

Please describe.

No

Do you have any physical or mental disabilities?

Yes

Please describe.

No

Do you have any life threatening disease or condition?

Yes

Please describe.

No

Do you provide primary or other major financial support to adult children/grandchildren or others?

Yes

Who?

No

Do you have any pets?

Yes

No

Do you have a prepaid burial account/burial plot?

Yes

No

Children

Child 1: Name

Date of Birth

Address

Phone Number

Email

Check all that apply:

DisabledMarriedSingle

If child is not joint, indicate other biological parent

Child 2: Name

Date of Birth

Address

Phone Number

Email

Check all that apply:

DisabledMarriedSingle

If child is not joint, indicate other biological parent

Child 3: Name

Date of Birth

Address

Phone Number

Email

Check all that apply:

DisabledMarriedSingle

If child is not joint, indicate other biological parent

Please provide details for children or grandchildren with any special needs or disabilities:

Please provide details for children or grandchildren that have substance abuse problems, creditor problems, problems managing finances or marital issues that could affect their receiving property outright.

Additional information:

Income

Please list all income sources for YOURSELF, the amount, and the frequency.

Please list all income sources for YOUR SPOUSE, the amount, and the frequency.

Assets: Summary of Values

Primary home (include address)

Other real estate (include addresses). If married and not jointly owned, indicate ownership.

Automobiles, Boats, RVs. If married and not jointly owned, indicate ownership.

Bank and Savings Accounts (include name of bank). If married and not jointly owned, indicate ownership.

Safe Deposit Boxes (include name of bank). If married and not jointly owned, indicate ownership.

Stocks & Bonds (include name of brokerage firm). If married and not jointly owned, indicate ownership.

Annuities (include name of financial institution). If married and not jointly owned, indicate ownership.

Life Insurance (name of insurance company, type of insurance)

Long-term Care Insurance (name of insurance company, number of years of benefit)

Retirement Plans (include name of provider)

Business Interests (include name, type of company, family members involved with company)

Money owed to you (include debtor)

Anticipated inheritance (please specify)

Personal belongings with high or sentimental value

Electronic Assets (cryptocurrencies, domain names, NFTs, etc.)

Other Assets (please specify)

Liabilities: Summary of Values

Mortgages (include addresses)

Other Secured Debt (i.e. auto loan)

Other Unsecured Debt (i.e. credit card)

Potential Lawsuits

PERSONAL GOAL OF YOUR ESTATE PLAN

Please provide a brief summary of what you wish to accomplish by creating this estate plan.

Additional Contact (person who may be present at meetings, if any; provide name, relationship, phone number, and email address)

ITEMS TO CONSIDER WHEN YOU ARE PREPARING FOR INITIAL MEETING

Who do you want to name as the agent on your power of attorney? Please provide Name, Relationship, Street Address, and Phone Number for both Primary and Successor Agents.

Who do you want to name as the agent on your health care proxy? Please provide Name, Relationship, Street Address, and Phone Number for both Primary and Successor Agents.

Who do you want to name as the executor under your will? Please provide Name, Relationship, Street Address, and Phone Number for both Primary and Successor Agents.

Who do you want to name as the as the trustee for your trust? Please provide Name, Relationship, Street Address, and Phone Number for both Primary and Successor Agents.

Who do you want to name as the as the guardian for your minor children? Please provide Name, Relationship, Street Address, and Phone Number for both Primary and Successor Agents.

Are there any Allied Professionals (i.e. accountant, financial advisor, attorneys, etc.) whose name you would like to provide with whom your planning should be coordinated?

Do you have specific wishes regarding your health care in the event of your incapacity?

Do you have specific instructions regarding your burial?

Thank You!