Guardianship Intake Form

    Personal Information

    WARD

    GUARDIAN

    Name*

    Address

    City, State, Zip

    Home Phone

    Cell Phone

    Email*

    DOB

    Marital Status

    DOD
    DOD

    Spouse’s Name

    Citizenship

    SSN

    Occupation

    Occupation Status

    Military Status

    Dates of Service:

    Dates of Service:

    Children

    How Many:

    How Many:

    Grandchildren

    How Many:

    How Many:

    Guardian’s Relationship to Ward: Do you have Power of Attorney?

    Referred by: Name: Company:

    Financial Advisor: Firm: Phone:

    Accountant: Firm: Phone:

    Brief Explanation as to why I am applying for guardianship:

    Any other details we should know regarding the ward:

    Ward’s Estate Planning

    EXISTING ESTATE PLAN

    WARD

    LOCATION OF DOCS

    DATE EXECUTED

    Will

    Trust

    Power of Attorney

    Health Care Proxy

    Living Will

    Long-Term Care Insurance

    Funeral & Burial Plans

    Ward’s Health

    Current health status:

    Specific concern/problem:

    Does ward require long term care?

    If receiving care currently, please indicate the facility and date of admission:

    Has the ward ever been in a hospital or rehab facility for thirty days or more?

    Ward’s Family

    List all of ward’s CHILDREN and immediate family (if applicable)

    Name: Date of Birth:

    Address:Phone:

    Child of:Other relation

    - Occupation:

    - how long? Spouse’s name: Occupation:

    Children: How many? Ages:

    Special needs/considerations:

    Potential problems/hardships/issues:

    Name: Date of Birth:

    Address:Phone:

    Child of:Other relation

    - Occupation:

    - how long? Spouse’s name: Occupation:

    Children: How many? Ages:

    Special needs/considerations:

    Potential problems/hardships/issues:

    Name: Date of Birth:

    Address:Phone:

    Child of:Other relation

    - Occupation:

    - how long? Spouse’s name: Occupation:

    Children: How many? Ages:

    Special needs/considerations:

    Potential problems/hardships/issues:

    Name: Date of Birth:

    Address:Phone:

    Child of:Other relation

    - Occupation:

    - how long? Spouse’s name: Occupation:

    Children: How many? Ages:

    Special needs/considerations:

    Potential problems/hardships/issues:

    Name: Date of Birth:

    Address:Phone:

    Child of:Other relation

    - Occupation:

    - how long? Spouse’s name: Occupation:

    Children: How many? Ages:

    Special needs/considerations:

    Potential problems/hardships/issues:

    Name: Date of Birth:

    Address:Phone:

    Child of:Other relation

    - Occupation:

    - how long? Spouse’s name: Occupation:

    Children: How many? Ages:

    Special needs/considerations:

    Potential problems/hardships/issues:

    Name: Date of Birth:

    Address:Phone:

    Child of:Other relation

    - Occupation:

    - how long? Spouse’s name: Occupation:

    Children: How many? Ages:

    Special needs/considerations:

    Potential problems/hardships/issues:

    Name: Date of Birth:

    Address:Phone:

    Child of:Other relation

    - Occupation:

    - how long? Spouse’s name: Occupation:

    Children: How many? Ages:

    Special needs/considerations:

    Potential problems/hardships/issues:

    Your Finances

    MONTHLY INCOME: ** It is very important you indicate in each category ownership and dollar amount separately, as well as total value.**

    SOURCE

    WARD

    SPOUSE

    JOINT

    TOTAL

    Wages

    $

    $

    $

    $

    Pension

    $

    $

    $

    $

    Social Security

    $

    $

    $

    $

    Investments

    $

    $

    $

    $

    Other

    $

    $

    $

    $

    Total Value

    $

    $

    $

    $

    TYPE OF ASSET

    WARD

    SPOUSE

    JOINT

    TOTAL

    Cash, Checking, Savings, CDs, Money Market & Cash Management Accounts

    $

    $

    $

    $

    Investment/Broker-held Accounts (not including cash) and Mutual Fund Accounts

    $

    $

    $

    $

    Retirement Accounts: IRA, 401K, 403B, SEP, etc.

    $

    $

    $

    $

    Life Insurance: death benefit and cash value

    D.B. $

    C.V. $

    D.B. $

    C.V. $

    D.B. $

    C.V. $

    D.B. $

    C.V. $

    Stocks you hold outside of brokerage accounts

    $

    $

    $

    $

    Bonds you hold outside of brokerage accounts

    $

    $

    $

    $

    Annuities: $ = original amount invested date=month/year purchased CV=current value

    $

    date

    CV

    $

    date

    CV

    $

    date

    CV

    $

    date

    CV

    Real estate: residence (per tax bill)

    $

    $

    $

    $

    Real estate: other

    $

    $

    $

    $

    Vehicles: automobile, motorcycle, boats, snowmobiles, etc.

    $

    $

    $

    $

    Total Value

    $

    $

    $

    $

    OTHER ASSETS NOT LISTED:

    TYPE

    WARD

    SPOUSE

    JOINT

    TOTAL

    $

    $

    $

    $

    $

    $

    $

    $

    Total Value

    $

    $

    $

    $

    LIABILITIES:

    TYPE

    WARD

    SPOUSE

    JOINT

    TOTAL

    Mortgage

    $

    $

    $

    $

    Loans Payable

    $

    $

    $

    $

    Amount Withheld from Social Security for Medicare

    $

    $

    $

    $

    Cost of Medicare Supplement

    $

    $

    $

    $

    Other

    $

    $

    $

    $

    Total Value

    $

    $

    $

    $

    BUSINESS INTERESTS:

    TYPE

    WARD

    SPOUSE

    JOINT

    TOTAL

    Farm

    $

    $

    $

    $

    Partnership or LLC Interest

    $

    $

    $

    $

    Corporation

    $

    $

    $

    $

    Other:

    $

    $

    $

    $

    Total Value

    $

    $

    $

    $

    Notes/Comments: